Date: _______________
WAKE FOREST BAPTIST HEALTH
VOLUNTEER SERVICES
Confirmation of Volunteer Orientation / Annual In-Service
Name: _________________________
SECTION I - To be completed at Volunteer Orientation / Annual In-Service
I am aware of the Department of Volunteer Services policies and procedures and/or
practice standards for the following:
Mission/Values
Patient Rights/Responsibilities
Corporate Compliance & HIPAA Awareness
Policies and Procedures
General Safety & Security/Fire/Disaster
Infection Control
Employee Health Requirements
Patient and Family-Centered Care
Armed Threat Preparedness Training
I understand the material presented and I pledge that I will be dependable and that I will abide
by regulations. If completed electronically, checking this box signifies an electronic signature.
For Patient and Family Advisor volunteers only: By checking this box I am signifying that I
have completed the Patient and Family Advisor general orientation.
___________________________________
Signature
Please complete:
Emergency Contact Name: _____________________________ Relationship: _____________
Section II - To be completed at
annual In-Service Training Please note Changes Only:
Volunteer Name: __________________________________________________________
Address: __________________________________________________________
City, State, Zip: __________________________________________________________
Phone:
_
_______________ (Home) E-Mail Address: ___________________________
________________ (Work)
________________ (Cell)
Phone:
_______________ (Home)
_______________ (Work)
_______________ (Cell)
WAKE FOREST BAPTIST HEALTH
NON-EMPLOYEE
CONFIDENTIALITY AGREEMENT
1
Wake Forest University Health Sciences and North Carolina Baptist Hospital, along with their
subsidiaries (collectively, “the Medical Center”) have, and will develop further, confidential,
proprietary information and trade secrets relating to their clinical, research and educational
missions.
These trade secrets and confidential and proprietary information include but are not limited to,
information concerning patients, research studies and subjects, animal care and use, faculty,
staff, and students, planning, financial and donor information, prices, pricing methods, costs,
procedures or processes for the Medical Center’s business, fixtures, research and development
methods, projects, data, goals or activities, business strategies, research techniques, the identities
or addresses of the Medical Center’s employees or their functions, confidential reports prepared
for the Medical Center by business consultants, or any other information concerning the Medical
Center or its business that is not readily and easily available to the public or to those in the
Medical Center’s business (any and all of which shall be referred to in this Agreement as
“Information”). In the course of my relationship with the Medical Center, I may have access to
such Information, and I understand and acknowledge the importance of protecting the
confidentiality of such Information.
In consideration of my continued relationship, by signing this Agreement, I understand and agree
to the following:
1. I may use Information disclosed to me solely in the course of my relationship with the Medical
Center. I may not use Information for any other purpose.
2. During and after my relationship, I will hold all Information in the strictest confidence and
will not disclose any Information or any portion of the Information to any other firm, entity,
institution, or person, except that I may disclose the Information on a confidential basis to other
employees and agents of the Medical Center on a “need to know” basis in the course of my
relationship with the Medical Center. I understand and agree that my obligation to keep
Information confidential forbids me to disclose Information even to family members or friends,
and even when identifying details are not revealed.
3. I understand and agree that all property of and data and records with respect to the Medical
Center and its affiliates coming into my possession or kept by me in connection with my
relationship with the Medical Center, including without limitation, correspondence, management
studies, research records, notebooks, blueprints, computer programs, software and
documentation, bulletins, reports, patient lists, student and employment data, costs, purchasing
and marketing information, are the exclusive property of the Medical Center. I agree to return to
the Medical Center all such property and all copies of such data and records upon termination of
my relationship or as otherwise directed by the Medical Center.
4. I understand that the Information is of a private, internal, or confidential nature and constitutes
a valuable, special and unique asset of the Medical Center and its affiliates.
5. I understand a material breach of this Agreement will cause irreparable damage to the Medical
Center and its affiliates, and that such damage will be difficult to quantify and for which money
damages alone will not be adequate. Accordingly, I agree that the Medical Center, in addition to
any other legal rights or remedies available to the Medical Center on account of a breach or
threatened breach of this Agreement, shall have the right to obtain an injunction against me
WAKE FOREST BAPTIST HEALTH
NON-EMPLOYEE
CONFIDENTIALITY AGREEMENT
2
enjoining any such breach without the need for posting a bond, and I waive the defense in any
equitable proceeding that there is an adequate remedy at law for such breach.
6. I will not access any Information or area of the Medical Center that I have not been authorized
to access. I will not discuss Information in areas where others who do not have a need to know
such Information may overhear the conversation (e.g. hallways, elevators, cafeterias, shuttle
buses, public transportation, restaurants, and social events).
7. I will not access any Information for other persons or employees who do not have the right to
access the Information themselves. I will not disclose my or any other Medical Center
employee's computer password(s) to anyone, nor will I use another person’s password(s) instead
of my own for any reason unless authorized by my point of contact or unless required by the
Medical Center's Information Systems Department for maintenance reasons. I will inform my
point of contact immediately if I know or have reason to believe someone without proper
authority knows or is using my password(s).
8. I will not:
a. make any personal or unauthorized inquiries* into any Medical Center computer or
system;
b. make any personal or unauthorized transmissions*
i
of any Information;
c. modify any Information without authority to do so;
d. purge any Information without authority to do so.
9. I will log off, lock, or restart any computer prior to leaving it unattended.
10. I will inform my Medical Center point of contact, or other appropriate personnel of any
known or suspected unauthorized disclosure or misuse of Information which I observe or of
which I become aware.
11. I will protect Medical Center Information stored on a laptop computer by:
a. Encrypting all Information stored on the laptop,
b. Temporarily storing Information (during active use only) on the laptop, and
c. Maintaining a current secure backup of all Information stored on the laptop (network,
CD, DVD etc).
12. Any Information that I am authorized to store on removable storage media (e.g. CD’s,
DVD’s, PDA’s, USB/flash drives, external hard drives etc) will be store in a secure manner (that
is, with password protection and/or encryption)
13. I will immediately report to my Medical Center point of contact if said media or any
Information is ever lost or stolen.
14. I will secure (encrypt) all transmissions (email, file transfers, etc) that contain Confidential
Information in accordance with the Medical Center Information Security and Privacy Policies.
15. I understand that public (i.e. non- Medical Center) wired and wireless networks should not be
considered secure for any reason. Therefore, whenever I am connected to a computer network
other than the Medical Center’s conducting Medical Center business, I will use the Medical
WAKE FOREST BAPTIST HEALTH
NON-EMPLOYEE
CONFIDENTIALITY AGREEMENT
3
Center’s Portal (https://portal.wfubmc.edu) or VPN (Virtual Private Network) software to access
the Medical Center’s resources remotely.
16. I understand and agree that this Agreement shall be governed by and construed in accordance
with the laws of the State of North Carolina and any claim or dispute arising from the terms or
performance of this Agreement will be submitted to the jurisdiction of the state or federal courts
of North Carolina, and I consent to the exclusive jurisdiction of such Courts.
17. I understand that any violation of the terms of this agreement may result in termination of my
relationship with the Medical Center and/or termination of my access to Medical Center
information and/or the Medical Center facility as applicable. I further understand that all of my
computer activity, including e-mail and Internet use, is subject to auditing or monitoring by the
Medical Center.
I acknowledge that I have read this agreement, understand its terms, and agree to abide by both
this agreement and the Medical Center’s Information Security and Privacy Policies and all other
policies in effect where applicable concerning the security and privacy of Information.
I further understand and acknowledge that nothing contained in this agreement creates a
contract regarding the term of my relationship with the Medical Center, express or implied.
By checking this box, I acknowledge that I have read and understand this agreement.
i
* Unauthorized inquiries or transmissions include, but are not limited to, reviewing, removing, printing, and/or
transferring Information from any Medical Center computer or paper filing systems to unauthorized locations, e.g.
home computer, personal laptop, USB drives, CD/DVD, or other portable media.
Direct any questions concerning this agreement to the Medical Center Privacy Office 336-713-HIPA
Name: ________________________
Date: ________________________
1 | TJC/OSHA Course 1 (FY2017)
TJC/OSHA – Workplace Safety and Security
FY 2017 Test
Volunteer Name (First, Middle Initial, Last):
Department Number: 811060 Department Name: Volunteer Services
EnvironmentofCare
1) The Fire/Disaster/Safety (FDS) Manual can be found:
On The Joint Commission’s official website
On the EH&S IShare site
Through Purchasing
2) Where can you find emergency response templates for your department to use?
In the FDS Quick Reference Flip Chart.
In Carpenter Library's reference section.
At the Incident Command Center
GeneralSafety
3) Select the wise guidelines for lifting. There is more than one correct choice.
Bend your knees with your back upright.
Use your back to lift, not your leg muscles.
Carry the load higher than your waist.
If it doesn’t seem safe to lift it alone, ask for help!
4) Who is primarily responsible for a volunteer’s safety?
The Joint Commission
The volunteer
The Environmental Health and Safety Department
A coworker
5) As a volunteer of Wake Forest Baptist Health System, you bear responsibility to
contribute to a safe environment for patients, staff and others who enter our
facilities.
True
False
2 | TJC/OSHA Course 1 (FY2017)
6) How do you report an employee/volunteer incident or injury?
Use the Fire/Disaster/Safety (FDS) Manual
Use the Occurrence Reporting link found on the Intranet.
Call OSHA
MedicalCenterSecurity
7) What is the number to call for reporting emergencies?
Inpatient campuses: 6-HELP; Innovation Quarter: 3-1568; Others: 911
Inpatient campuses: 6-9111; Innovation Quarter: 3-1568; Others: 911
Inpatient campuses: 6-1111; All other locations: 336-716-1111
8) When a suspected child abduction is announced overhead, staff should respond by
monitoring hallways and exits.
True
False
9) Which non-emergency incidents should you report to Security?
Car trouble
Suspicious activities
Thefts (not in progress)
Water intrusions
All of the above
3 | TJC/OSHA Course 1 (FY2017)
TJC/OSHA – Fire & Life Safety and Medical Equipment
FY 2017 Test
FireandLifeSafety
1) What is a smoke compartment?
A designated smoking area
An area of refuge that prevents fire and smoke from spreading throughout a floor
An area to evacuate patients to during fire drills only
2) How will a magnetically locked door (maglock door) unlock in the event of an
emergency?
Master release switch at nurse's station
Automatically upon fire alarm activation
Emergency release switch located near the magnetic locked door
All of the above
3) When should you push the emergency HVAC shutoff button?
Never
When you need help from Facilities
To adjust the thermostat
When you see or smell smoke coming from a vent
4) When operating a fire extinguisher, remember “PASS,” which stands for:
Push, Alarm, Soak, Stop
Pull, Aim, Squeeze, Sweep
Panic, Asphyxiate, Sit, Surrender
Press, Aim, Spray, Saturate
5) In the event of a fire, remember “RACE,” which stands for:
Rescue, Alarm, Contain, Extinguish
Rescue, Activate, Control, Elevator
Resuscitate, Alert, Call, Evaluate
4 | TJC/OSHA Course 1 (FY2017)
6) In the Defend In Place evacuation strategy of a patient care unit, which of these
things happens first?
Move patients vertically down the nearest stairwell.
Remove equipment from the egress hallways.
Move patients horizontally into the next smoke compartment.
It is best to use the elevators during a fire.
7) Once the decision has been made to evacuate a patient care unit, which statement is
true?
While equipment is being removed from the hallways, patients should be assessed
and prepared for the proper evacuation hierarchy.
There is no need to assess patients’ clinical needs for evacuation until after all
equipment is removed from the hallways.
Delay evacuation as long as possible.
8) What equipment essential to patient care is allowed to stand in a corridor?
In-use PPE carts and crash carts
unattended beds or stretchers
unattended wheelchairs
unattended mobile work stations
9) It is everyone's responsibility to help keep hospital corridors clear and unobstructed.
True
False
10) Power strips must be approved by Engineering before use.
What other statement below is also true?
Power strips should occupy a red outlet whenever possible.
Power strips must not be overloaded with heat-producing devices.
Power strips may be laid across high traffic corridors.
5 | TJC/OSHA Course 1 (FY2017)
TJC/OSHA – Hazard Communication
FY 2017 Test
HazardCommunication
1) Appropriate ‘Personal Protective Equipment’ (PPE) should be used, based on your
tasks and on the SDS of any chemical involved.
True
False
2) Fit testing for respirators should occur on what time interval?
Once a month
Upon start of employment only
Annually, or whenever changes occur that would require a repeat of fit testing
3) If there is a chemical spill that you cannot safely contain by yourself, you should:
(Select all that would apply)
Evacuate the area
Turn off ignition sources (if it is safe to do so)
Close all doors
Call your Emergency number (6-9111, 3-1568, or 911)
4) At what point should an oxygen cylinder be stored with the empties?
At 1/2 full
At 1/4 full
At 1/8 full
5) Where should batteries be disposed of?
A sharps container
Any standard trash receptacle
A Universal Waste bucket
6) Good examples of Regulated Medical Waste would be:
Band-aids; Gauze with a small speck of blood
Batteries; Gloves
Food waste; Newspapers
Used needles (sharps); Containers with more than 20 ml of blood
6 | TJC/OSHA Course 1 (FY2017)
TJC/OSHA – Emergency Management and Utility Systems
FY 2017 Test
EmergencyManagement
1) What is meant by “Medical Surge Plan Phase One Has Been Activated?”
The ED is seeing first signs of moderate crowding.
Due to severe crowding, critical services supervisors will join efforts to manage patient
throughput.
The Hospital Incident Command Center will now set up and begin coordinating operations.
The Virtual Personnel Pool will now be implemented.
2) In order for you to successfully receive an emergency communication from the
WFBMC Emergency Alert System, you must:
Keep your personal contact information in PeopleSoft up to date.
Log in to MIR3 and update your contact information.
3) A “Phase Three” Major Disaster Response could be activated for:
A plane crash
A fire on campus
An extreme weather event
Any of the above disasters
4) If you do not have a specific job assignment in the Major Disaster Plan, then your
role is to:
Go directly to the Emergency Department.
Report to your supervisor for instructions.
Do nothing unless approached personally by a member of the Emergency
Management Committee.
5) Under the HICS Disaster Management System, the person responsible for setting
strategies and priorities during an incident is the:
Safety Officer
Liaison Officer
Incident Commander
Medical Technical Specialist
7 | TJC/OSHA Course 1 (FY2017)
UtilitySystems
6) In the event of a fire, who authorizes the shutdown of oxygen to a patient care unit?
Environmental Services (EVS)
Security Officer
Engineering Technician
The Charge Nurse or the Clinician
7) What items must be plugged into the red power outlets?
Desktop computers
Multifunction printers
Equipment critical to patient care
Heat-producing devices
8) Which of the following may be flushed down a toilet in our facilities?
Flushable wipes
Paper towels
Sani-wipes
None of the above
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