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Are you currently a student?
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Currently employed
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A record of criminal conviction will not necessarily be a bar to volunteering, since the Hospital will consider factors such as age at time of offense, how long ago the conviction occurred, the nature and seriousness of the violation and evidence of rehabilitation in making a volunteer decision. Since Children?s is a pediatric hospital, certain criminal offenses are by Ohio law automatic disqualifiers for volunteer assignments no matter when they occurred.
In the past seven years, have you been convicted of (plead guilty, no contest, or been found guilty) an offense other than minor traffic violations?
Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication, or dropping of the charge?
If yes to any background check question, please explain:
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HIPAA/Confidentiality/Security Training
In order to comply with HIPAA (Health Insurance Portability and Accountability Act), other privacy laws, and other
health care accreditation guidelines as well as professional ethics standards, it is imperative that all Shadows
understand, respect and follow the Akron Children's Hospital confidentiality policy. We ask that you read this
"Confidentiality Statement" carefully. We will keep your signed copy on file. Please ask an Akron Children's
Hospital employee if you have any questions or concerns regarding this confidentiality requirement.
I understand that by virtue of my presence at Akron Children's Hospital, I may be informed of certain health
information that is necessary to accomplish the goals of my visit or may inadvertently receive such information. To
insure HIPAA and other privacy laws are not violated, I understand Akron Children's Hospital's policy not to share
any health information about another person.
By signing below, I acknowledge that I will keep confidential all health information that I become aware of during
my visit. This includes information about any health condition, testing, treatment, surgery, medications, or
procedures related to the health of an individual. In addition, I agree not to use or to disclose this information
to any person.
I understand that as a Shadow I am responsible for maintaining the confidentiality of all information related to
Akron Children's Hospital. This Agreement prohibits the unauthorized verbal, written or electronic communication of
any information about patients, families, physicians, employees, donors, and volunteers which is of a medical,
personal, or financial nature, including the fact a patient was admitted to the Hospital or to any other Akron
Children's Hospital facility.
I also understand and agree, as part of being a Shadow, that what I see, hear or read in any Akron Children's
Hospital facility pertaining to the above may only be discussed on the premises with members of staff for purposes
which benefit the organization's stated objectives.
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Akron Children's Hospital (ACH) and its subsidiary organizations are dedicated to providing a healthy work
environment for all who enter our campus. The goal is for all individuals providing services on behalf of ACH to
embrace the Mission of the Hospital.
MISSION
S ervice to the Community intended to improve the health status through lay education.
P atient care for infants, children, adolescents and burn victims of all ages.
E ducation for students of medicine, nursing, and the various allied health professions.
A dvocacy for child and family to improve the status of children and adolescents.
R esearch into the causes, treatment and cure of childhood illness/injury and burn injury.
EMERGENCY CODES Emergency situations are announced by color via overhead page. The phone number to report any emergency situation
is "22." If an emergency code is announced, you are to follow the direction of Children's employees.
PATIENT RIGHTS
All patients have the right to have personal and medical information kept confidential. Discussing any hospital or
patient information with anyone who does not have a bona fide need to know is prohibited. Your assigned department
will educate you regarding any privacy issues that relate to the Health Insurance Portability and Accountability
Act (HIPAA) which are federal regulations that safeguard protected health information.
INFECTION CONTROL
Infections are easily spread by hands. Follow the hand hygiene policy by either washing with soap and water or
using an alcohol-based hand sanitizer (such as Purell) before and after every patient contact. Follow the Body
Substance Precautions Policy by wearing protective equipment such as gowns, gloves and masks.
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I hereby affirm that the information provided on this application is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for volunteer service and may result in discharge even if discovered at a later date. I understand the terms and conditions of my submission to the background check. I authorize Akron Children's Hospital to verify any information I have provided. I hereby authorize persons from any schools, companies, or organizations, to include my references, named in this application to provide information about me contained in their records, and I release all such persons from liability regarding the provision of or use of such information. I understand there are certain training requirements that must be fulfilled, and performance standards that must be maintained in order to volunteer at Akron Children's Hospital.
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has my permission to be a Project Volunteer at Akron Children's Hospital.
Typed Name Constitutes Signature
Authorization to Consent to Treatment of Minor
a minor, do hereby authorize Akron Children's Hospital to consent to any diagnostic, medical, surgical treatment of
hospital care which is determined necessary by a licensed physician on the medical staff of Akron Children's
Hospital. This authorization is valid when such diagnostics, treatment or care is considered by the physician or
surgeon to be reasonably necessary to preserve the life of, or prevent serious impairment to, the health of the
teen project volunteer and the minor's parent/legal guardian is not immediately available to consent to such
treatment.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care
being required to provide specific consent to act in situations described above until such time as a parent or
legal guardian is available to act on behalf of the teen.
This authorization will remain in effect until the minor's eighteenth birthday, unless revoked in writing and
presented to the Volunteer Services Department of Akron Children's Hospital.
Typed Name Constitutes Signature
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