Volunteer Policy Acknowledgement Form
I have read, understand, and agree to the following policies:
Informed Consent for WVU Medicine Volunteer Services Program Participants
I agree to take part in the Volunteer Services Program at WVU Medicine. I understand that volunteers are not permitted to provide or assist with direct patient care. Some examples of direct patient care include, but are not limited to, giving medication, bandaging, injections, suturing, and bathing. If I am unsure of what to do in a given circumstance, I will seek advice from my immediate supervisor. If I feel that my supervisor has not provided me with sound ethical advice, then I will refer to the hospital’s compliance plan and I will call the compliance hotline that is included in my orientation packet.
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I agree.
Behavioral Standards
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I agree.
Dress Code
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I agree.
HIPAA
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I agree.
Patient Rights & Responsibilities
*
I agree.
Name:
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First Name
Last Name
By checking this box, you have created an electronic signature as legally binding as your hand-written signature
*
I agree.
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If you are under the age of 18, your parents must fill out the following items:
Parent name
First Name
Last Name
By checking this box, you have created an electronic signature as legally binding as your hand-written signature
I agree.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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