Fillable Volunteer Application Volunteer Application (CITY OF BROWNWOOD)

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Volunteer Application Volunteer Application (CITY OF BROWNWOOD)

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  • 2 check-boxes
  • 67 other fields

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U.S.A. forms for CITY OF BROWNWOOD

BROWSE CITY OF BROWNWOOD (TX) FORMS

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Brown County MRC Volunteer Application Page 1 of 2
BROWN COUNTY MEDICAL RESERVE CORPS VOLUNTEER APPLICATION
Personal Information – Please PRINT LEGIBLY and complete all information.
Name:
Gender: Female Male
Last First
Middle
Address:
Street Address
City/Town, State
Zip Code
Phone:
Home Work
Cell/Mobile
Alternate
Email (Home):
Email (Work):
Occupation:
Employer:
I am a licensed health care provider.
Type of License:
I would like to be a non-medical volunteer.
(MD, Pharmacist, RN, LVN,
EMT, LPC etc.)
List any special skills/training/abilities you believe would be of assistance in case of a health
emergency: i.e. list languages spoken or read, sign language (ASL, other), TTY/TDD, computer
skills, construction skills, communication skills, warehouse knowledge/skills, truck driving
experience, counseling skills, etc.
Driver’s License #:
Expiration:
(mm/dd/yyyy)
(mm/dd/yyyy)
Emergency Contact:
Name
Relationship
Phone
Volunteer Requirements & Responsibilities:
1. Volunteers must submit an application to Public Health Preparedness at the
Brownwood/Brown County Health Department and be willing to register and maintain
contact information with TDVR at the time of application approval.
2. Volunteers must be at least 18 years of age.
3. U.S. citizenship is not required; however, volunteers must present a valid Texas driver's
license with their application and at the time of orientation.
VOLUNTEER APPLICATION
Brown County MRC Volunteer Application Page 2 of 2
4. Volunteers must pass the DPS Computerized Criminal History Check, and must remain
free of felony and serious misdemeanor convictions.
5. Volunteers will agree to abide by and sign the Brown County MRC Code of Conduct and
Liability Policy (Appendix A).
6. Volunteers will agree to abide by and sign the Health Insurance Accountability and
Portability Act (HIPAA) Policy (Appendix B).
7. Participate in all required training sessions.
8. Notify the Brown County MRC Director, in writing, when terminating volunteer status.
9. Be available on short term notice.
I understand:
That any information I have provide in this application may be disclosed to and used by the
Brown County MRC and the Brownwood/Brown County Health Department for planning
purposes and volunteer assignment ONLY.
Due to the variable nature of work and the potential duties of volunteers, a background check
will be conducted on volunteer applicants.
I understand that a felony conviction for D.W.I., drug-related, sexual, or family violence
offenses will disqualify me for participation as a Brown County MRC volunteer and that I may
be disqualified for other reasons at the discretion of the Brown County MRC Director and/or
Brownwood/Brown County Administrator.
All information regarding the Brown County MRC is considered confidential, and I will not
release names, locations of warehouses, or any other sensitive information.
That, in the case of MRC deployment, I may be contacted at any time, day or night.
I have read and understand the above listed requirements, responsibilities, and information. I
attest to the accuracy of the information I have provided on this application. I hereby authorize the
City of Brownwood/Brown County to receive and disclose my information to the Brown County MRC
Director/Coordinator and the Health Administrator for the purposes and reasons stated above.
MRC Volunteer Printed Name
MRC Volunteer Signature
Date
MRC Director/Coordinator Printed Name
MRC Director/Coordinator Signature
Date
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signature
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signature
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RELEASE AND WAIVER AGREEMENT
I, ___________________________________, a volunteer for the City of Brownwood, do
hereby, for myself, heirs, executors and administrators, release and discharge the City of
Brownwood and all its officers, agents and employees, acting officially or otherwise,
from any and all claims, demands, actions, or causes of actions, on account of my death
or on account of any injury to myself which may occur from any cause, including,
without limitation, any negligent act of the City, the City’s officers, agents and
employees, whether such negligent act was the sole proximate cause of the injury or
damage or a proximate cause jointly and concurrently with myself, arising out of my
participation in the City of Brownwood’s volunteer work activities.
I further understand and acknowledge that the City’s decision to allow my participation
as a volunteer for the City of Brownwood is made in reliance on this release and waiver
agreement.
______________________________ ____________________________
Signature of Volunteer Today’s date
______________________________ ____________________________
Printed Name of Volunteer Last 4 digits of Social Sec #
______________________________ ______________________________
Address City & State
_____________________________ ______________________________
Date of Birth D/L State / Expiration Date
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signature
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DPS
Computerized
Criminal History (CCH)
Verification
(AGENCY
COPY)
I,
_____________
acknowledge that
a
Computerized
Criminal
APPLICANT or EMPLOYEE NAME (Please print)
History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure
Website
and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority for this
agency
to access an
individual’s
criminal history data may be found in Texas Government Code 411; Subchapter F.
Name-based information is not an exact search and only fingerprint record searches represent true
identification to criminal history, therefore the organization conducting the criminal history check is not
allowed to discuss with me any criminal history record information obtained using this method. The
agency
may request that I have a fingerprint search performed to clear any misidentification based on the result of
the
name and DOB search. Once this process is completed the information on my fingerprint criminal
history
record may be discussed with
me.
In order to complete the process I must make an appointment with the Fingerprint Applicant Services
of
Texas (FAST) as instructed online at www.txdps.state.tx.us / Crime Records / Review of Personal Criminal
History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of
fingerprints,
request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting
services
company.
(This copy must remain on file by your agency. Required for future DPS
Audits
)
Signature of Applicant or Employee
Please:
Check and Initial each Applicable
Space
Date
CCH Report Printed:
City of Brownwood
Agency Name (Please print)
YES NO_____
Purpose
of CCH:
initial
Agency
Representative
Name
(P
l
ease
print)
Emp.
_
Vol/Contracto
r
initial
Date
Printed:
initial
Signature of Agency Representative
Destroyed
Date:
initial
Date
Retain
in your
files
Rev. 09/2013
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signature
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IMMUNIZATION REGISTRY (ImmTrac2)
ADULT CONSENT FORM
(Please print clearly)
Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347
PROVIDERS REGISTERED WITH ImmTrac2: Please enter client information in ImmTrac2 and afrm that consent
has been granted. DO NOT fax to ImmTrac2. Retain this form in your client’s record.
Stock No. F11-13366 Revised 09/2017
By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas
immunization registry.
Individual (or individual’s legally authorized
representative):
Printed Name
Signature
Date
ImmTrac2, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The
immunization registry is a secure and condential service that consolidates immunization records for public health purposes
(e.g., giving all doctors treating a patient a central place to see that patient’s immunization records). With your consent, your
immunization information will be included in ImmTrac2. For a family member younger than 18 years of age, a parent, legal guardian,
or managing conservator may grant consent for participation for that minor by completing the ImmTrac2 Minor Consent Form (# C-7). The
ImmTrac2 Minor Consent Form (# C-7) can be downloaded by visiting www.ImmTrac.com.
The Texas Department of State Health Services encourages your
voluntary participation in the Texas immunization registry.
Consent for Registration and Release of Immunization Records to Authorized Persons / Entities
I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I
further understand that DSHS will include this information in the state’s central immunization registry, ImmTrac2. Once in
ImmTrac2, my immunization information may by law be accessed by:
• a Texas physician, or other health care provider legally authorized to administer vaccines, for treatment of the individual
as a patient;
• a Texas school in which the individual is enrolled;
• a Texas public health district or local health department, for public health purposes within their areas of jurisdiction;
• a state agency having legal custody of the individual;
• a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records
relating to the specic individual covered under the payor’s policy.
I understand that I may withdraw this consent at any time.
Gender:
Male Female
Date of Birth
Address Apartment # Telephone
--
Last Name
City State Zip Code County
Mother’s First Name Mother’s Maiden Name
Middle NameFirst Name
Privacy Notication: With few exceptions, you have the right to request and be informed about information that the State
of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right
to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more
information on Privacy Notication. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Brown County MRC Code of Conduct Page 1 of 2
BROWN COUNTY MEDICAL RESERVE CORPS CODE OF CONDUCT
All volunteers of the Brown County Medical Reserve Corps (MRC) shall meet the
following standards of conduct. As a volunteer of the Brown County MRC, I agree to:
Ethical Conduct
•
Maintain and abide by the standards of my profession, including licensure,
certification and/or training requirements to support my MRC role
•
Report changes to professional licensure, including suspension or termination, to
the MRC Coordinator
•
Act in the capacity of a MRC responder and present myself as a MRC volunteer only
with prior authorization/deployment by the MRC Coordinator or the
Brownwood/Brown County Health Department
•
Avoid inappropriate conduct and behavior, including behavior that is dangerous to
others or myself (e.g., acts of violence, verbal or physical abuse, harassment)
•
Avoid situations that could be interpreted as a conflict of interest
•
Abstain from the use of city and state equipment and resources for personal use
•
Refrain from transporting, storing, or consuming alcoholic beverages or illegal
substances while performing volunteer duties
•
Abstain from responding for duty under the influence of alcohol or illegal substances
or under the influence of prescription or non-prescription medication that may
influence my abilities
•
Refrain from accepting or seeking on behalf of myself or any other person, any
financial advantage or gain as a result of my affiliation with the MRC
•
Abstain
from publicly using my MRC affiliation in connection with the promotion of
partisan politics, religious matters, or positions on any issue
•
Avoid knowingly taking any action or making any statement intended to influence the
conduct of the MRC in such a way as to confer any special benefit on any person,
corporation, or entity in which I have an interest or affiliation
•
Contact the MRC Coordinator as soon as possible if I am not able to
participate after registering and being deployed to any event, emergency
response, or training
•
Abstain from the use of audio or video recording equipment, unless authorized
•
Keep contact information current in the Texas Disaster Volunteer Registry (TDVR)
CODE OF CONDUCT
Brown County MRC Code of Conduct Page 2 of 2
Safety
•
Put safety first in all volunteer activities
•
Wear my MRC badge when deployed to any MRC-sponsored activity or while on site at
the Brownwood/Brown County Health Department
•
Dress for the environment and wear closed toe footwear, if activated to respond
•
Respect and use all equipment appropriately
•
Promote healthy and safe work practices
•
Take care of self and others
•
Report injuries, illnesses, accidents, safety hazards, and suspicious activity to the
appropriate staff member
Respec
t
•
Refrain from using and disclosing any protected information, to which I may have
access, to any person not authorized to receive such information
•
Avoid commenting with, answering questions, or divulging information to the media
•
Respect the cultures, beliefs, opinions, and decisions of others, although I may not
always agree
•
Treat others with courtesy, sensitivity, tact, consideration, and humility
•
Accept the chain of command and respect others regardless of their position
MRC Volunteer Printed Name
MRC Volunteer Signature
Date
MRC Director/Coordinator Printed Name
MRC Director/Coordinator Signature
Date
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Brown County MRC Privacy and Liability Policy Page 1 of 1
BROWN COUNTY MEDICAL RESERVE CORPS HIPAA & LIABILITY POLICY
ACKNOWLEDGMENT
Health Insurance Portability and Accountability Act (HIPAA) Protects Patient Privacy
As a volunteer performing duties for the Brownwood/Brown County Health Department -
Public Health Preparedness, you will have access to the Protected Health Information
(PHI) of our clients. The fact that an individual is or was a client of the BBCHD is PHI.
Federal and state laws, including HIPAA and our policies and procedures, protect the
privacy and security of this PHI.
It is illegal for you to use or disclose PHI outside the scope of your volunteer duties for the
BBCHD. This includes oral, written, or electronic uses and disclosures.
The following are guidelines for using public health information:
You may use PHI as necessary to carry out your duties as a volunteer
You may share PHI with other health care providers for treatment purposes
You may NOT photocopy PHI
You must access only the minimum amount of PHI necessary to care for a
patient or to carry out an assignment
You may NOT record PHI (such as patient names, diagnoses, dates of birth,
addresses, phone numbers, etc.) on any assignments you may need to turn
into your instructor, reports you may need to turn in to your program, or
forms you may need to take with you
You may only access the PHI of patients for whom you are caring/volunteering
when there is a need for the PHI
Be aware of your surroundings when discussing PHI. For example,
because others may overhear you, it is inappropriate to discuss PHI in
bathrooms, lunch areas or in any other public place
When disposing of any documents with PHI, do NOT put them into a waste can.
Instead, place discarded documents with PHI into containers marked for
shredding/shred in designated location
If you have questions about the use or disclosure of PHI, contact the Medical
Reserve Corps Coordinator
PRIVACY & LIABILITY POLICY
MRC Volunteer Printed Name
MRC Volunteer Signature
Date
MRC Director/Coordinator Printed Name
MRC Director/Coordinator Signature
Date
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Volunteer Application Volunteer Application (CITY OF BROWNWOOD)

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Completed 16 July 2020

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