Fillable City of Bainbridge Island Emergency Management Volunteer Program (City of Bainbridge Island)

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City of Bainbridge Island Emergency Management Volunteer Program (City of Bainbridge Island)

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BROWSE CITY OF BAINBRIDGE ISLAND (WA) FORMS

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Page 1 of 14
City of Bainbridge Island Emergency Management Volunteer Program
Overview:
The City of Bainbridge Island (“City”) recognizes the important contributions community
volunteers make in the aftermath of a disaster. The City’s Emergency Management (EM)
Program offers a number of volunteer positions for residents who are interested in
becoming part of the City’s disaster response plan.
This form is the first step in the City’s EM volunteer review and assessment process. All
potential volunteers will complete a background investigation, be screened, and be
matched to positions according to their skills and abilities in order to best serve and
protect residents and current volunteers. The City reserves the right to deny volunteer
service. The data furnished on this form is provided on a voluntary basis and will be used
to contact, interview, and place volunteers.
Notices:
Personal Injury and Reporting: Volunteers are not considered to be City employees. Injury
compensation is provided through the Washington State Department of Labor &
Industries. All volunteers are required to submit a Volunteer Timesheet for this purpose.
Timesheets must be submitted to the Emergency Management Coordinator on a quarterly
basis.
Volunteer Limitations: Volunteers must stay within the attached Scope of Work. Activities
performed outside or in excess of the volunteer’s Scope of Work will be considered
unauthorized and may lead to termination.
Provision of Personal Protective Equipment (PPE): The City will provide PPE as required for
the Scope of Work and identified by the Washington Industrial Safety and Health Act. All
volunteers requiring PPE will be provided adequate training in its proper care and use.
Volunteers are responsible for supplying basic PPE per City of Bainbridge Island
Volunteer/Emergency Worker Code of Conduct.
Page 2 of 14
Training: All training received by volunteers will be documented, signed by the volunteer,
and provided to the City’s Human Resources Department.
Use of Personal Vehicles/Mileage Reimbursement: The City will reimburse for mileage for
volunteers who routinely drive a personal vehicle as part of their volunteer duties, not to
include mileage from the home of residence to City Hall or other meeting locations. A
valid driver’s license issued within the United States and personal automobile insurance are
required for expenses to be reimbursed. This policy also includes fuel reimbursement for
marine vessels, provided that a Captain’s license, if applicable, and the insurance provisions
above are met. Reimbursement is based on the IRS Mileage Rate at the time of travel.
Volunteers must submit a completed City Travel Reimbursement form to be reimbursed.
Emergency Management Volunteers are not authorized to drive City vehicles.
Termination: The City and/or the volunteer may terminate this service at any time without
cause. The termination will be effective immediately upon the provision of written notice.
Page 3 of 13
City of Bainbridge Island Emergency Management Volunteer Application
GENERAL APPLICANT INFORMATION
Full Name: _________________________________ Birth Date: ____________________
Address: ______________________________________________________________________
Primary Phone: ______________________________ Alternate Phone: _______________
Email: ______________________________________
Driver’s License Number: ______________________ State: ______ Exp: ______________
Sex: _______ Height: _______ Weight: _______ Hair Color: _______ Eye Color: _______
TRAINING/CERTIFICATIONS/LICENSURE & PAST DISASTER EXPERIENCE INFORMATION
Check all that apply:
CPR (List expiration date): _____________
First Aid (List expiration date): ___________________
NIMS/ICS Courses (List all): _________________________________________________________
Medical License (List type and expiration date): ____________________________________
Veterinary Medical License (List type and expiration date): _________________________
HAM Radio Call Sign: ____________________
Boat Captain License (List type and expiration date): _______________________________
Previous disaster volunteer experience: _____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Other: _______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Page 4 of 13
EMERGENCY CONTACT INFORMATION:
Primary Emergency Contact Name: _________________________________________________
Relationship: ____________________________
Address: ______________________________________________________________________
Primary Phone: ___________________________ Alternate Phone: ______________________
Alternate Emergency Contact Name: ________________________________________________
Relationship: _____________________________
Address: ______________________________________________________________________
Primary Phone: ___________________________ Alternate Phone: ______________________
PLEASE INDICATE WHICH POSITION YOU WOULD LIKE TO APPLY FOR:
Community Emergency Response Team (CERT) Member
Emergency Operations Center Volunteer
Flotilla Volunteer
General Hub Volunteer
General Support Volunteer
Ham Radio Operator
Hub/Shelter Manager Volunteer
Medical Reserve Corps (MRC) Volunteer
Warming Center/Shelter Volunteer
Wilderness First Responder (WFR) Volunteer
VOLUNTEER AFFIRMATION
I, _________________________________________, hereby volunteer my services for the City of
Bainbridge Island’s Emergency Management Program in accordance with the attached
Scope of Work. I understand I will not be compensated for my work. Further, I hereby
certify that I am capable of performing the duties outlined in the attached Scope of Work
__with or __ without the accommodation(s) listed.
List of accommodations: _________________________________________________________
_____________________________________________________________________________
Page 5 of 13
In consideration of giving me permission to perform these volunteer services, I agree to
the following terms:
1. I will not appear for volunteer service under the influence of any drugs or alcohol.
2. If after being accepted as a volunteer with the City’s Emergency Management Plan,
I am arrested for or charged with any criminal offense, I will report my arrest or
charge within seven (7) days of my arrest or the filing of any criminal charge.
3. I will abide by the City’s Emergency Worker/Volunteer Code of Conduct (attached).
4. I agree not to exceed the Scope of Work for my volunteer position without prior
authorization from the City’s Emergency Management Coordinator or on-scene
City or Fire District official in charge.
5. Should I be injured while performing authorized volunteer work, I understand that
the City has included my hours of volunteer service in the Washington State
Department of Labor and Industries coverage for volunteer workers.
6. I will report any on-the-job injury or illness, no matter how minor, to the City’s
Human Resources Staff.
7. I consent to the City performing a criminal history background check in accordance
with RCW 43.43.830-839 and waive any right of privacy I may have in such
information for the limited purpose of considering it for determining my suitability
as a volunteer. Further, I release the City of Bainbridge Island and those
individuals/institutions that provide information from any liability that may arise
from the provision of this information.
8. The City may terminate this agreement at any time without cause. I am volunteering
my services at will and may be asked to discontinue such without prior notice or
reason.
9. I am fully aware that the work associated with being a volunteer involves certain
risks of physical injury or death. Being fully informed as to these risks and in
consideration of my being allowed to participate in the Emergency Management
Volunteer Program, I hereby assume all risk of injury, damage, and harm to myself
arising from such activities. I also hereby individually and on behalf of my heirs,
executors, and assignees, release and hold harmless the City, its officials,
employees, and agents and waive any right of recovery that I might have to bring a
claim or lawsuit against them for any personal injury, death or other consequences
occurring to me arising out of my volunteer activities, except for those caused by
the sole negligence of the City of Bainbridge Island.
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10. I authorize any necessary emergency medical treatment that might be required for
me in the event of physical injury and/or accident to me while participating in this
program.
11. I have read, understand, and agree to abide by the Personal Responsibilities of an
Emergency Worker (WAC 118.04.200) (attached).
12. I have read and understand the Immunity from Liability for Covered Volunteer
Workers (RCW 38.52.180) (attached).
13. I give permission for photos/videos taken of myself during volunteer activities to be
used for publicity purposes without recompense.
14. This agreement will be in effect for the duration of my volunteer services.
Signature: ___________________________________________
Printed Name: _______________________________________
Dated this__________ day of___________, 20_____.
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National Background Screening Consent Form
Applicant’s Legal Name (printed)
________________________________________________________
Social Security Number __________________ Date of Birth _________
Applicant’s Address
________________________________________________________
City ___________________________State _________Zip __________
I, ____________________________, authorize and give consent for the above
named organization to obtain information regarding myself. This includes the following:
• Local & National Criminal background records/information
• All 50 State Sex Offender Registries
• Full Address Trace
• Social Security Verification
I the undersigned, authorize this information to be obtained either in writing or via
telephone in connection with my application. Any person, firm or organization providing
information or records in accordance with this authorization is released from any and all
claims of liability for compliance. Such information will be held in confidence in
accordance with the City of Bainbridge Island’s guidelines.
By signing this document, I am providing the City of Bainbridge Island my consent for an
initial background check as well as any subsequent background checks deemed necessary.
Print Name:__________________________ Date:_________________
Signature: _______________________________________________________________
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Page 8 of 13
Personal Responsibilities of Emergency Workers (WAC 118.04.200)
(1) Emergency workers shall be responsible to certify to the authorized officials registering
them and using their services that they are aware of and will comply with all applicable
responsibilities and requirements set forth in these rules.
(a) Emergency workers have the responsibility to notify the on-scene authorized
official if they have been using any medical prescription or other drug that has the
potential to render them impaired, unfit, or unable to carry out their emergency
assignment.
(b) Participation by emergency workers in any mission, training event, or other
authorized activity while under the influence of or while using narcotics or any illegal
controlled substance is prohibited.
(c) Participation by emergency workers in any mission, training event, or other
authorized activity while under the influence of alcohol is prohibited.
(d) Emergency workers participating in any mission, training event, or other
authorized activity shall possess a valid operator's license if they are assigned to operate
vehicles, vessels, or aircraft during the mission unless specifically directed otherwise by an
authorized official in accordance with RCW 38.52.180. All emergency workers driving
vehicles to or from a mission must possess a valid driver's license and required insurance.
(e) Use of private vehicles, vessels, boats, or aircraft by emergency workers in any
mission, training event, or other authorized activity without liability insurance required by
chapter 46.29 RCW is prohibited unless specifically directed otherwise by an authorized
official in accordance with RCW 38.52.180.
(f) Emergency workers shall adhere to all applicable traffic regulations during any
mission, training event, or other authorized activity. This provision does not apply to
individuals who have completed the emergency vehicle operator course or the emergency
vehicle accident prevention course and who are duly authorized under state law to use
Page 9 of 13
special driving skills and equipment and who do so at the direction of an authorized
official.
(2) Emergency workers have the responsibility to comply with all other requirements as
determined by the authorized official using their services.
(3) When reporting to the scene, emergency workers have the responsibility to inform the
on-scene authorized official whether they are mentally and physically fit for their assigned
duties. Emergency workers reporting as not fit for currently assigned duties may request a
less demanding assignment that is appropriate to their current capabilities.
(4) Emergency workers have the responsibility to check in with the appropriate on-scene
official and to complete all required recordkeeping and reporting.
Page 10 of 14
Immunity from Liability for Covered Volunteer Workers (RCW 38.52.180)
(1) There shall be no liability on the part of anyone including any person, partnership,
corporation, the state of Washington or any political subdivision thereof who owns or
maintains any building or premises which have been designated by a local organization for
emergency management as a shelter from destructive operations or attacks by enemies of
the United States for any injuries sustained by any person while in or upon said building or
premises, as a result of the condition of said building or premises or as a result of any act
or omission, or in any way arising from the designation of such premises as a shelter, when
such person has entered or gone upon or into said building or premises for the purpose of
seeking refuge therein during destructive operations or attacks by enemies of the United
States or during tests ordered by lawful authority, except for an act of willful negligence by
such owner or occupant or his or her servants, agents, or employees.
(2) All legal liability for damage to property or injury or death to persons (except an
emergency worker, regularly enrolled and acting as such), caused by acts done or
attempted during or while traveling to or from an emergency or disaster, search and
rescue, or training or exercise authorized by the department in preparation for an
emergency or disaster or search and rescue, under the color of this chapter in a bona fide
attempt to comply therewith, except as provided in subsections (3), (4), and (5) of this
section regarding covered volunteer emergency workers, shall be the obligation of the
state of Washington. Suits may be instituted and maintained against the state for the
enforcement of such liability, or for the indemnification of persons appointed and regularly
enrolled as emergency workers while actually engaged in emergency management duties,
or as members of any agency of the state or political subdivision thereof engaged in
emergency management activity, or their dependents, for damage done to their private
property, or for any judgment against them for acts done in good faith in compliance with
this chapter: PROVIDED, That the foregoing shall not be construed to result in
indemnification in any case of willful misconduct, gross negligence, or bad faith on the part
of any agent of emergency management: PROVIDED, That should the United States or any
agency thereof, in accordance with any federal statute, rule, or regulation, provide for the
payment of damages to property and/or for death or injury as provided for in this section,
Page 11 of 14
then and in that event there shall be no liability or obligation whatsoever upon the part of
the state of Washington for any such damage, death, or injury for which the United States
government assumes liability.
(3) No act or omission by a covered volunteer emergency worker while engaged in a
covered activity shall impose any liability for civil damages resulting from such an act or
omission upon:
(a) The covered volunteer emergency worker;
(b) The supervisor or supervisors of the covered volunteer emergency worker;
(c) Any facility or their officers or employees;
(d) The employer of the covered volunteer emergency worker;
(e) The owner of the property or vehicle where the act or omission may have
occurred during the covered activity;
(f) Any local organization that registered the covered volunteer emergency worker;
(g) The state or any state or local governmental entity; and
(h) Any professional or trade association of covered volunteer emergency workers.
(4) The immunity in subsection (3) of this section applies only when the covered volunteer
emergency worker was engaged in a covered activity:
(a) Within the scope of his or her assigned duties;
(b) Under the direction of a local emergency management organization or the
department, or a local law enforcement agency for search and rescue; and
(c) The act or omission does not constitute gross negligence or willful or wanton
misconduct.
(5) For purposes of this section:
(a) "Covered volunteer emergency worker" means an emergency worker as defined
in RCW 38.52.010 who (i) is not receiving or expecting compensation as an emergency
worker from the state or local government, or (ii) is not a state or local government
employee unless on leave without pay status.
Page 12 of 14
(b) "Covered activity" means:
(i) Providing assistance or transportation authorized by the department
during an emergency or disaster or search and rescue as defined in RCW 38.52.010,
whether such assistance or transportation is provided at the scene of the
emergency or disaster or search and rescue, at an alternative care site, at a hospital,
or while in route to or from such sites or between sites; or
(ii) Participating in training or exercise authorized by the department in
preparation for an emergency or disaster or search and rescue.
(6) Any requirement for a license to practice any professional, mechanical, or other skill
shall not apply to any authorized emergency worker who shall, in the course of performing
his or her duties as such, practice such professional, mechanical, or other skill during an
emergency described in this chapter.
(7) The provisions of this section shall not affect the right of any person to receive benefits
to which he or she would otherwise be entitled under this chapter, or under the workers'
compensation law, or under any pension or retirement law, nor the right of any such
person to receive any benefits or compensation under any act of congress.
(8) Any act or omission by a covered volunteer emergency worker while engaged in a
covered activity using an off-road vehicle, nonhighway vehicle, or wheeled all-terrain
vehicle does not impose any liability for civil damages resulting from such an act or
omission upon the covered volunteer emergency worker or the worker's sponsoring
organization.
Page 13 of 14
City of Bainbridge Island Volunteer/Emergency Worker Code of Conduct
1. Volunteers will not use their position for their own personal benefit.
2. Volunteers will not seek or accept any financial advantage or gain that may be
offered as a result of the volunteer’s affiliation with the City. Any known or potential
conflicts of interest must be disclosed to the City’s Emergency Management
Coordinator within seven days.
3. Volunteers will not publicly utilize any City affiliation in connection with the
promotion of partisan politics or religious matters.
4. Volunteers will not disclose any confidential information that is available solely as a
result of their service, to any person not authorized to receive such information, or
use to the disadvantage of the City any such confidential information, without the
express authorization of the City.
5. Volunteers will not knowingly take any action or make any statement intended to
influence the conduct of the Volunteer Group in such a way as to confer any
financial benefit on any person, corporation, or entity in which the individual has
significant interest or affiliation.
6. Volunteers will operate and/or act only in a manner that is in the best interests of
the City.
7. Volunteers will not engage in any inappropriate behavior that would jeopardize the
program’s effectiveness and sustainability, to include: profane language, public
criticism of a team member, or purposefully jeopardizing the safety of the public or
a team member.
8. Volunteers do not have a legal duty to act and are not required to respond to
incidents in the immediate area, nor to recall requests. Once responded, however,
volunteers must follow safe and effective practices at all times. Volunteers who
abandon their duty assignment, act outside of their training or Scope of Work, or
otherwise violate policies or this Code of Conduct are subject to termination.
9. Volunteers will report all unsafe situations, activities or practices immediately and
take appropriate protective action for themselves and bystanders.
10. Volunteers will bring or wear appropriate Personal Protective Equipment (PPE):
hard hat, vest, dust mask, goggles, gloves (latex and/or leather), sturdy shoes, long
Page 14 of 14
pants, flashlight, bottled water, food, etc. Shorts, sandals, and open-toed shoes are
strictly prohibited when responding to an incident and/or training event. If scope of
work requires certain PPE, the City will provide it.
11. Volunteers will limit their actions to their physical and resource abilities as
determined by, but are not limited to, equipment availability, physical abilities,
knowledge, authority, and hazards.
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City of Bainbridge Island Emergency Management Volunteer Program (City of Bainbridge Island)

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Completed 2 August 2020

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