Housing and Patient Services Volunteer Participant and Confidentiality Agreement

After completing this form, please complete the Housing and Patient Services Volunteer Competency Test.

Asterisk (*) indicates a required field.

Participant Agreement

I have requested to be a volunteer participant at St. Jude Children's Research Hospital, Inc. ("St. Jude") for the Housing and Patient Services Volunteer Program. I understand that my services as a volunteer participant are important to the research, education, and outreach of St. Jude.

I agree to treat all information that I may hear about patients, families, or hospital personnel as confidential. I understand that Federal law protects patients from having their personal health information impermissibly used or disclosed and that the breaking of confidentiality could result in my immediate dismissal as a volunteer. I understand that confidentiality is essential to the effective functioning of any department that utilizes volunteers.

I agree to serve as a volunteer as agreed to by the Housing and Patient Services Volunteer staff and myself. I understand that my services are that of a volunteer and not as an employee of St. Jude. My services are given without contemplation of future employment, and are given for humanitarian, religious, or charitable reasons.

I agree to notify my volunteer supervisor if I am unable to work as scheduled and will remove myself from my scheduled shift online. I will not report to work with a temperature of 38.0°C (100.4°F) or greater, have had diarrhea or vomited in the last 24 hours, have an active infection with measles, mumps, chicken pox, shingles, boils, infected lesions of the hands, streptococcal pharyngitis ("strep throat") or conjunctivitis (pink eye) or have cold or flu-like symptoms (cough, runny nose, sneezing, chills, shortness of breath, body aches, or loss of sense of smell or taste)).

I have been instructed in and understand the Universal Precautions policy and the safety procedures in place at St. Jude and will conduct myself accordingly. I have been informed that hazardous biological and chemical materials, including radioactive substances, are used in the research areas at St. Jude, and I agree to adhere to all applicable safety guidelines.

I agree to abide by the policies and procedures set forth in the St. Jude Children’s Hospital Housing and Patient Services Volunteer Orientation Manual, including St. Jude's Fire Plan R.A.C.E. I fully understand the Infection Control policies and procedures and any additional information provided to me by my department supervisor and other St. Jude personnel. Other areas included in orientation are age-specific competencies, ergonomics, life safety and utilities management, substance abuse, security, information management and the patient abuse policies.

I understand St. Jude will hold harmless and defend me against third-party claims based on services I perform, in good faith as part of my authorized responsibilities under this Agreement.

I understand that St. Jude may use my image, likeness and voice. Some events at St. Jude may be broadcast via radio, television, the internet and mobile devices. Many are also photographed or recorded for later broadcast or other uses. St. Jude from time to time, in its sole discretion, may (or may contract with others to) photograph, film, and record certain footage that may include voice, image and/or likeness of volunteers for promotional, training, marketing, or other business purposes. If you do not wish to be filmed or photographed, please avoid areas where cameras are present at St. Jude events.

Confidentiality Agreement

As a workforce member, as defined under the Health Insurance Portability and Accountability Act (HIPAA) of St. Jude, I understand that I may have access to certain confidential, health, financial, proprietary, research, patient or operational information of St. Jude, its employees and the patients and their families (collectively known as "Confidential Information"). I further acknowledge that St. Jude has a legal and ethical obligation to protect this Confidential Information. This same obligation applies to me while as a volunteer of St. Jude.

In recognition of this responsibility, which constitutes an essential function as a volunteer of St. Jude, I agree as follows:

1. All Confidential Information at St. Jude shall be treated as confidential. I will not access or seek to gain access to Confidential Information of any nature whatsoever except in the course of fulfilling my responsibilities.

2. I agree not to discuss patient, human resources, payroll, fiscal, research or business information or other Confidential Information where others can overhear the conversation, e.g., in hallways, on elevators, in the cafeterias, on public transportation, at restaurants, at social events. It is not acceptable to discuss clinical or patient information in public areas, even if a patient's name is not used. This can raise doubts with patients and visitors about our respect for their privacy.

3. If, in the course of performing my responsibilities, I accidentally access information or Confidential Information that might be considered inappropriate for me to access, I will notify [my supervisor] immediately of the date and time of the access so that if a question arises at a later time, it will be understood that the access was accidental. I will not disseminate any such information without proper authorization.

4. I will not use another person's sign-on or computer password or allow another individual to use my sign-on or computer password to gain access to Confidential Information or information which may be considered confidential without proper authorization. I will not disclose Confidential Information to those who are not authorized to receive it. In addition, I will not, without proper authorization, copy or preserve in written, electronic, or any other form Confidential Information, nor will I disseminate any such information without proper authorization. If I am in doubt about whether the authorization provided is "proper", I will consult staff from Volunteer Services for guidance. These obligations shall continue both during and after termination of membership in volunteer with St. Jude.

5. I agree to follow St. Jude's Email, Internet and Electronic Protected Information policies, which include all use of Social Media (e.g. Instagram, Twitter, Facebook, LinkedIn, etc.). I will not exchange personal information or communicate in any way with St. Jude patients and family members outside of my volunteer shifts, via such personal channels as phone, email, or on social media sites.

6. I will not take photographs or videos while on campus without direct permission of Housing and Patient Services Volunteer staff members.

7. Violation of this Agreement may subject me to corrective action, up to and including termination, as well as penalties and legal action by state and/or federal agencies.

8. I understand that the Housing and Patient Services Volunteer Coordinators reserve the right to terminate my volunteer status as a result of:

a. failure to comply with St. Jude policies, rules and regulations

b. absences without prior notification

c. unsatisfactory attitude, work or appearance

d. any circumstances which, in the judgement of the Housing and Patient Services Volunteer Coordinators would make my continued services as a volunteer contrary to the best interests of St. Jude

It is also understood that I may terminate my services as a volunteer if I become unable to continue my services under this Agreement.

My initials below acknowledge that I understand the obligations imposed upon me by this Agreement, and I agree to comply with all the terms of this Agreement.