Date: _______________
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:
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 chec
king this box I am signifying that I
have completed the
Patient and Family Advisor general
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: __________________________________________________________
_______________ (Work) E-Mail Address: ___________________________
________________ (Home)
________________ (Cell)
_______________ (Work)
_______________ (Home)
_______________ (Cell)
I acknowledge that I have read and understand the guiding principles described in our Code
of Conduct. If completed electronically, checking this box signifies an electronic signature.
Wake Forest University Baptist Medical Center and its affiliates and subsidiaries (collectively “WFUBMC”) creates,
develops, receives, maintains, transmits, and transacts confidential, proprietary, and trade secret information to
achieve its clinical, research, and educational missions (“Confidential Information”).
WFUBMC’s Confidential Information includes Protected Health Information (“PHI”), education records, fiscal records,
research records, computer system records, and other management information deemed confidential for business
purposes as further defined by WFUBMC’s Confidentiality of Information Policy or as specified in the agreement
WFUBMC has with you or your employer for your services.
During and in consideration of my engagement with WFUBMC, I understand, acknowledge, and agree to the
following terms of this Confidentiality and Nondisclosure Acknowledgment (“ Acknowledgment”):
1. I may be required to access, use, create, develop, receive, maintain, transmit, transact, and/or disclose
(collectively “Activity”) Confidential Information.
2. I will limit my Activity involving Confidential Information to what is necessary for me to perform my services and to
what is an appropriate, permitted, and approved purpose (collectively “Acceptable Purpose”). My Activity
involving Confidential Information will not be for any other purpose.
3. I recognize that any Activity that involves or relates to Confidential Information that is not for an Acceptable
Purpose is unauthorized (“Unauthorized”).
4. During and after my engagement, I will hold Confidential Information in the strictest confidence and will not
divulge any Confidential Information to any other firm, entity, institution, or person without proper authority.
5. My Activity may require me to share Confidential Information with WFUBMC employees, contractors, advisors,
consultants, and other WFUBMC approved resources or personnel and I will do so on an authorized “need to
know” basis only.
6. I recognize that Confidential Information constitutes a valuable, special, and unique asset of WFUBMC. I further
recognize and agree that all Confidential Information, in any physical, electronic, or other format, to which I am
exposed is the exclusive property of WFUBMC and shall be returned to WFUBMC, including all copies thereof,
upon termination of my engagement or as otherwise directed by WFUBMC.
7. I understand that, as part of my role and as related to my services, I may receive confidential information from
third-party individuals, providers, or entities, which may include confidential information available through (a)
Epic’s Care Everywhere; (b) federal, state, and other health information exchanges; and (c) other databases
(collectively “Third-Party Confidential Information”). I agree that my Activity involving or related to Third-Party
Confidential Information shall only be for an Acceptable Purpose and shall be conducted in accordance with the
terms of this Confidentiality Acknowledgment and WFUBMC’s policies and procedures. I agree to protect
Third-Party Confidential Information as I would WFUBMC’s Confidential Information under this
8. My Activity will abide by and follow WFUBMC’s applicable policies and procedures. Activities addressed under
such policies and procedures include but are not limited to the following:
I will not discuss Confidential Information in areas where others who do not have a need to know the
Confidential Information may overhear the conversation (e.g. hallways, elevators, cafeterias, shuttle
buses, public transportation, restaurants, and social events).
I will not engage in Activity involving or related to Confidential Information for other persons or employees
who do not have the authorization to access the Confidential Information themselves.
I understand that passwords and other security credentials are Confidential Information and as such will
not share them and will protect them as Confidential Information. I will inform my WFUBMC Sponsor
and Information Technology and Services if I know or have reason to believe someone knows, is or may
be using my passwords or security credentials.
I will log off, lock, or restart my computer prior to leaving it unattended and understand that all of my
computer Activity, including e-mails and Internet use, is subject to auditing or monitoring by WFUBMC.
I will encrypt all emails, file transfers, and other electronic transmissions that contain Confidential
Information in accordance with the Information Security and Encryption Policies.
I will immediately, or as soon as practical, inform my WFUBMC Sponsor, or other appropriate personnel
of any known or suspected unauthorized disclosure, misuse, or breach of Confidential Information of
which I reasonably believe occurred and will immediately, or as soon as practical, report if any
Confidential Information is lost or stolen.
I understand that copying and/or storing Confidential Information on any personal or non-WFUBMC
controlled device is strictly prohibited. I agree that my electronic Activity shall only be performed on a
WFUBMC controlled device. I will only store Confidential Information on removable disk media (e.g. CD’s,
DVD’s, USB/flash drives, etc.) when necessary and then only in an encrypted and approved manner.
I understand that public (i.e. non- WFUBMC) wired and wireless networks should not be considered
secure for any reason. Therefore, whenever I am connected to a computer network other than
WFUBMC’s, I will only use WFUBMC authorized remote access technologies.
9. I will cooperate fully during any review or investigation related to my Activity and my compliance with the terms of
this Confidentiality Acknowledgment.
10. I will comply with all applicable federal laws, including but not limited to the Health Information Portability and
Accountability Act, as amended (“HIPAA”), the Family Educational Rights and Privacy Act (FERPA), as well as all
applicable North Carolina and local laws.
11. I understand that if I violate this Acknowledgment, WFUBMC may terminate my access to Confidential
information. . I further understand that I may be subject to any applicable sanctions or disciplinary actions as
determined by my or my employer’s relationship and agreements with WFBMC, up to and including termination of
that relationship or agreement.
12. I understand and agree that this Acknowledgment is governed by North Carolina law and applicable federal
laws. I consent to exclusive jurisdiction in the state or federal courts of North Carolina for any claim or dispute
arising out of or related to the terms or performance under this Acknowledgment.
13. I understand that a breach of this Confidentiality Acknowledgment will cause irreparable damage to WFUBMC
and that such damage will be difficult to quantify monetarily. Accordingly, I permit WFUBMC to obtain an
injunction against me, which will prohibit me from breaching this Confidentiality Acknowledgment and I agree
that WFUBMC shall not be required to post a bond when seeking an injunction against me.
I acknowledge that I have read this Confidentiality Acknowledgment and understand its
If completed electronically, checking this box signifies an electronic signature.
Wake Forest Baptist Health
Volunteer Services ID Badge Procedure
Parking Regulations
I have read and understand the rules concerning ID badge procedures, and the parking regulations. I
understand that the Medical Center does not assume any liability for loss or damage to any vehicle or
its contents when parked in Medical Center parking facilities.
If completed electronically, checking this box signifies an electronic signature.
All Volunteers will be responsible for having a Medical Center ID Badge made before beginning their
volunteer assignment.
Pictures for ID Badges will be taken in Medical Center Identification, located on the ground Floor of
Meads Hall.
Hours: 7:30 a.m. – 4:00 p.m.
Days: Monday – Friday
Before obtaining a badge, Volunteers must report to the Volunteer Office to receive a form to
guarantee Human Resources that you are eligible for a photo ID.
The completed form should be taken to Human Resources at the above stated times. No appointment
is needed.
There will be no charge to the Volunteer for an initial ID Badge. If the badge is lost, the cost to replace
the badge will be $10.00. Badges are the property of the Medical Center and must be returned when
your Volunteer assignment is completed.
Please take your badge with you and keep up with it, wearing it on the upper part of your body.
Complimentary parking is provided for volunteers in the Patient Visitor Parking Deck C. You will enter
the deck from the Emergency Department entrance to the Medical Center on Cloverdale Avenue using
the parking
deck entrance to the right. You will drive up to the orange level where you can park in any
available space. You can then access the connector from the deck to the Main level of Ardmore Tower.
You will have to take a parking ticket when you enter the deck and it will be your responsibility to stamp
the ticket when you come into Volunteer Services to sign in or out to guarantee free parking upon exit.
Please park free only on the days you are volunteering. If you are visiting the Medical Center for any
other reason, you would be expected to pay as any other guest of the Medical Center.
Annual Compliance and HIPAA Training
FY 2020
Volunteer Name (First, Middle Initial, Last):
Date: _______________________
-Choose the correct response.
1. In the event of a fire, remember RACE which stands for:
Rescue, Alarm, Contain, Extinguish
Rescue, Activate, Control, Elevator
Resuscitate, Alert, Call, Evaluate
2. 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
3. When a tissue is unavailable and you need to cough, which is the most
acceptable alternative?
Cough into your bare hands
Cough into the upper part of your sleeve
Turn your head and cough away from others
4. In which situation is it possible for bloodborne pathogen transmission to
Shaking hands with an infected person
Using a public telephone
Pushing a wheelchair
Having blood splashed into the eyes
Date: _______________
Confirmation of
Volunteer Behavioral Expectations Follow-up
I am aware of the Department of Volunteer Services policies and procedures and/or practice
standards for: Volunteer Behavioral Expectations Follow-up
I pledge that I have viewed the Volunteer Expectations Follow-up Presentation and
understand its contents.
If completed
electronically, checking this box signifies an electronic signature.
If "Submit" does not work, please save these forms to your
computer and email them to:
Or the forms can be printed and either mailed or dropped off.
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