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Volunteer Application
Volunteer Application Title Name (First and Last) Street Address City, State, Zip Code Home Phone Cell Phone E-Mail Address Date of Birth Are you a patient of the clinic? Marital Status (Optional) Languages Apt/Unit # Sex Todays Date

Patients that want to volunteer will be able to in non-medical areas only. Please check with the Volunteer Services Manager.

Availability Days and Times Available: (Please check all that apply) Monday Tuesday Wednesday Thursday Morning Morning Morning Morning Afternoon Afternoon Afternoon Afternoon Evening Evening Evening Evening Interests Why did you choose to volunteer at the Venice Family Clinic? Friday Morning Afternoon Evening

Tell us in which areas you are interested in volunteering Advocacy Administrative Work Billing/ Data Entry Call Center Children First/ Early Head Start Children's Play Area Clinic Assitant HOPE Dental Assistant Dispensary/Pharmacy Front Office Health Education Health Insurance Homeless Outreach Medical Records Mental Health/Social Work Nurse Optometry/ Ophthalmology Patient Information Coordinator Translator/ Interpretor

Development /Events/ Fundraising Venice Art Walk Silver Circle Artist Cards Children's Holiday Movie

Special Skills and Qualifications Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports. Previous Volunteer Experience Summarize your previous volunteer experience.

Education and Training Dates Attended High School, University, Medical School, Internship, Residency, Fellowship Location Degrees/ Date Received

Person To Notify in Case of Emergency Name Relationship Home Phone Work Phone E-Mail Address Current Employer Dates Name of Employer Position Location

Confidentiality Agreement
It is the policy of this organization to provide equal opportunities without regard to race, religion, national origin, gender, sexual preference, age, or disability.

CONFIDENTIALITY AGREEMENT UCLA HEALTHCARE

Applies to all UCLA Healthcare workforce members including: employees, medical staff and other health care professionals; volunteers; agency, temporary and registry personnel; and trainees, housestaff, students, and interns (regardless of whether they are UCLA trainees or rotating through UCLA Healthcare facilities from another institution).

It is the responsibility of all UCLA Healthcare workforce members, as defined above, including employees, medical staff, house staff, students and volunteers, to preserve and protect confidential patient, employee and business information. The federal Health Insurance Portability Accountability Act (the Privacy Rule), the Confidentiality of Medical Information Act (California Civil Code 56 et seq.) and the Lanterman-Petris-Short Act (California Welfare & Institutions Code 5000 et seq.) govern the release of patient identifiable information by hospitals and other health care providers. The State Information Practices Act (California Civil Code sections 1798 et seq.) governs the acquisition and use of data that pertains to individuals. All of these laws establish protections to preserve the confidentiality of various medical and personal information and specify that such information may not be disclosed except as authorized by law or the patient or individual. Any individually identifiable Confidential Patient Care Information includes: information in possession or derived from a provider of health care regarding a patient's medical history, mental, or physical condition or treatment, as well as the patients and/or their family members records, test results, conversations, research records and financial information. (Note: this information is defined in the Privacy Rule as protected health information.) Examples include, but are not limited to: Physical medical and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples; Patient insurance and billing records; Mainframe and department based computerized patient data and alphanumeric radio pager messages; Visual observation of patients receiving medical care or accessing services; and Verbal information provided by or about a patient.

Confidential Employee and Business Information includes, but is not limited to, the following: Employee home telephone number and address; Spouse or other relative names; Social Security number or income tax withholding records; Information related to evaluation of performance;

Other such information obtained from the Universitys records which if disclosed, would constitute an unwarranted invasion of privacy; or Disclosure of Confidential business information that would cause harm to UCLA Healthcare.

Peer review and risk management activities and information are protected under California Evidence Code section 1157 and the attorney-client privilege. I understand and acknowledge that: 1. I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in connection with individual patient care, risk management and/or peer review activities. 2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and other confidential information relating to UCLA Healthcare and its affiliates, including business, employment and medical information relating to our patients, members, employees and health care providers. 3. I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of UCLA Healthcare, or where no officially adopted policy exists, only with the express approval of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the conduct of UCLA Healthcare affairs. 4. UCLA Healthcare Administration performs audits and reviews patient records in order to identify inappropriate access. 5. My user ID is recorded when I access electronic records and that I am the only one authorized to use my user ID. Use of my user ID is my responsibility whether by me or anyone else. I will only access the minimum necessary information to satisfy my job role or the need of the request. 6. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information. 7. I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a component of HIV, or antibodies or antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me subject to legal and/or disciplinary action. 8. I understand that the law specially protects psychiatric and drug abuse records, and that unauthorized release of such information may make me subject to legal and/or disciplinary action. 9. My obligation to safeguard patient confidentiality continues after my termination of employment with the University of California.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that the University of California may, as applicable and as it deems appropriate, pursue disciplinary action up to and including my termination from the University of California.
Volunteer Guidelines All volunteers must wear a volunteer name tag. Please keep cell phone use to a minimum. Please do not over socialize with staff during your volunteer shifts and staff work day. Please dress appropriately: clean, neat and intact clothing. We ask that all volunteers wear closed toe shoes. We ask that all volunteers wear clothing that is appropriate and not revealing. Please no tank tops or spaghetti straps. Please no t-shirts with questionable imagery. If you have questions please ask the VSS or your direct volunteer supervisor. If at any time you would like to change the program you're working in, please do not hesitate to call Volunteer Services. We would be happy to discuss other volunteer options with you and find a program that would most appeal to you. Please keep in mind that additional training may be required depending upon the program you choose and limited positions. Please do not ask any staff member to switch your volunteer position. Again, please contact Volunteer Services for this type of situation. Switching volunteer positions without approval of Volunteer Services may lead to terminating the volunteer relationship with Venice Family Clinic. Please maintain the confidentiality of fellow volunteers, staff and patients. The HIPPA/Confidentiality form you sign on your application is binding and we assure you that, unless you otherwise direct us, we will not release any information about you. We ask you to provide us with the same courtesy as relates to your volunteer work. You will be asked to keep track of the hours your volunteer hours. This is an important resource for our Clinic. When you enter the building, please report directly to your coordinator or on site supervisor and sign in. Once you leave the building, sign out so that we may accurately track your hours. Venice Family Clinic is a smoke-free environment. If you would like to smoke, please go to the designated smoking areas. Substance abuse, including alcohol and drugs, is not tolerated. If your program requires a minimum number of volunteer hours a week and/or that you attend support groups or in-services please make every attempt to be in attendance. If you must cancel, please let your Program Volunteer Coordinator know as soon as possible. Either party has the option of terminating the relationship for any reason, expressed or not.

Hepatitis B Acceptance/ Waiver Form

HEPATITIS B ACCEPTANCE/WAIVER FORM I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection.

I understand that the Hepatitis B vaccine series is recommended for my volunteer

category at the Venice Family Clinic. The series consists of three shots given at one, two and six months. The series is given only once in a person's lifetime.
I am going to make an appointment to receive the vaccine.

I have previously completed the vaccine series I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis E, a serious disease.

Sexual Harassment Policy

University of California Office of the President February 10, 2006 UNIVERSITY OF CALIFORNIA POLICY ON SEXUAL HARASSMENT A. Introduction The University of California is committed to creating and maintaining a community where all persons who participate in University programs and activities can work and learn together in an atmosphere free of all forms of harassment, exploitation, or intimidation. Every member of the University community should be aware that the University is strongly opposed to sexual harassment, and that such behavior is prohibited both by law and by University policy. The University will respond promptly and effectively to reports of sexual harassment, and will take appropriate action to prevent, to correct, and if necessary, to discipline behavior that violates this policy. This policy applies to the University of California campuses, the DOE Laboratories, the Medical Centers, and the Office of the President, including Agriculture and Natural Resources, and all auxiliary University locations (the locations).

B. Definition of Sexual Harassment Sexual harassment is unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, when submission to or rejection of this conduct explicitly or implicitly affects a person's employment or education, unreasonably interferes with a persons work or educational performance, or creates an intimidating, hostile or offensive working or learning environment. In the interest of preventing sexual harassment, the University will respond to reports of any such conduct. Sexual harassment may include incidents between any members of the University community, including faculty and other academic appointees, staff, coaches, house staff, students, and nonstudent or non-employee participants in University programs, such as vendors, contractors, visitors, and patients. Sexual harassment may occur in hierarchical relationships or between peers, or between persons of the same sex or opposite sex. In determining whether the reported conduct constitutes sexual harassment, consideration shall be given to the record of the conduct as a whole and to the totality of the circumstances, including the context in which the conduct occurred. This policy covers unwelcome conduct of a sexual nature. Consensual romantic relationships between members of the University community are subject to other University policies, for example, those governing faculty-student relationships are detailed in the Faculty Code of Conduct. 1 While romantic relationships between members of the University community may begin as consensual, they may evolve into situations that lead to charges of sexual harassment, subject to this policy.

Harassment that is not sexual in nature but is based on gender, sex-stereotyping, or sexual orientation also is prohibited by the Universitys nondiscrimination policies22 if it is sufficiently severe to deny or limit a persons ability to participate in or benefit from University educational programs, employment, or services. While discrimination based on these factors may be distinguished from sexual harassment, these types of discrimination may contribute to the creation of a hostile work or academic environment. Thus, in determining whether a hostile environment due to sexual harassment exists, the University may take into account acts of discrimination based on gender, sexstereotyping, or sexual orientation. C. Retaliation This policy also prohibits retaliation against a person who reports sexual harassment, assists someone with a report of sexual harassment, or participates in any manner in an investigation or resolution of a sexual harassment report. Retaliation includes threats, intimidation, reprisals, and/or adverse actions related to employment or education. D. Dissemination of the Policy, Educational Programs, and Employee Training As part of the Universitys commitment to providing a harassment-free working and learning environment, this policy shall be disseminated widely to the University community through publications, websites, new employee orientations, student orientations, and other appropriate channels of communication. The locations shall make educational materials available to all members of the University community to promote
1

The Faculty Code of Conduct may be found in Academic Personnel Manual (APM) section 015.

compliance with this policy and familiarity with local reporting procedures. In addition, the locations shall designate University employees responsible for reporting sexual harassment and provide training to those designated employees. Generally, such persons include supervisors, managers, academic administrators, deans, department chairs, student advisors, graduate advisors, residence hall staff, coaches, law enforcement officers, student judicial affairs staff, and health center staff. Each location shall post a copy of this policy in a prominent place on its website. E. Reports of Sexual Harassment Any member of the University community may report conduct that may constitute sexual harassment under this policy. In addition, supervisors, managers, and other designated employees are responsible for taking whatever action is necessary to prevent sexual harassment, to correct it when it occurs, and to report it promptly to the Title IX Compliance Coordinator (Sexual Harassment Officer) or other appropriate official designated to review and investigate sexual harassment complaints. An individual also may file a complaint or grievance alleging sexual harassment under the applicable University complaint resolution or grievance procedure (University of California Procedures for Responding to Reports of Sexual Harassment, Appendix I: University Complaint Resolution and Grievance Procedures). F. Response to Sexual Harassment The locations shall provide a prompt and effective response to reports of sexual harassment in accordance with the University of California Procedures for Responding to Reports of Sexual Harassment (Procedures). A prompt and effective response may include early resolution, formal investigation, and/or targeted training or educational programs. Upon findings of sexual harassment, the University may offer remedies to the individual or individuals harmed by the harassment consistent with applicable complaint resolution and grievance procedures (Procedures, Appendix I: University Complaint Resolution and Grievance Procedures). Such remedies may include counseling, an opportunity to repeat course work without penalty, changes to student housing assignments, or other appropriate interventions. Any member of the University community who is found to have engaged in sexual harassment is subject to disciplinary action up to and including dismissal in accordance with the applicable University disciplinary procedure (Procedures, Appendix II: University Disciplinary Procedures) or other University policy. Generally, disciplinary action will be recommended when the harassing conduct is sufficiently severe, persistent, or pervasive that it alters the conditions of employment or limits the opportunity to participate in or benefit from educational programs. Any manager, supervisor, or designated employee responsible for reporting or responding to sexual harassment who knew about the harassment and took no action to stop it or failed to report the prohibited harassment also may be subject to disciplinary action. Conduct by an employee that is sexual harassment or retaliation in violation of this policy is considered to be outside the normal course and scope of employment.
2

University of California Nondiscrimination and Affirmative Action Policy Regarding Academic and Staff Employment; Nondiscrimination and Affirmative Action Policy Statement for University of California Publications Regarding Employment Practices; Academic Personnel Policy 035, Affirmative Action and Nondiscrimination in Employment; Personnel Policies for Staff Members 12, Nondiscrimination in Employment; University of California Policies Applying to Campus Activities, Organizations, and Students; and Nondiscrimination Policy Statement for University of California Publications Regarding Student-Related Matters.

G. Intentionally False Reports Because sexual harassment frequently involves interactions between persons that are not witnessed by others, reports of sexual harassment cannot always be substantiated by additional evidence. Lack of corroborating evidence or proof should not discourage individuals from reporting sexual harassment under this policy. However, individuals who make reports that are later found to have been intentionally false or made maliciously without regard for truth, may be subject to disciplinary action under the applicable University disciplinary procedure (Procedures, Appendix II: University Disciplinary Procedures). This provision does not apply to reports made in good faith, even if the facts alleged in the report cannot be substantiated by an investigation. H. Free Speech and Academic Freedom As participants in a public university, the faculty and other academic appointees, staff, and students of the University of California enjoy significant free speech protections guaranteed by the First Amendment of the United States Constitution and Article I, Section I of the California Constitution. This policy is intended to protect members of the University community from discrimination, not to regulate protected speech. This policy shall be implemented in a manner that recognizes the importance of rights to freedom of speech and expression. The University also has a compelling interest in free inquiry and the collective search for knowledge and thus recognizes principles of academic freedom as a special area of protected speech. Consistent with these principles, no provision of this policy shall be interpreted to prohibit conduct that is legitimately related to the course content, teaching methods, scholarship, or public commentary of an individual faculty member or the educational, political, artistic, or literary expression of students in classrooms and public forums. However, freedom of speech and academic freedom are not limitless and do not protect speech or expressive conduct that violates federal or state anti-discrimination laws. I. Additional Enforcement Information The federal Equal Employment Opportunity Commission (EEOC) and the California Department of Fair Employment and Housing (DFEH) also investigate complaints of unlawful harassment in employment. The U.S. Department of Education Office for Civil Rights (OCR) investigates complaints of unlawful harassment of students in educational programs or activities. These agencies may serve as neutral fact finders and attempt to facilitate the voluntary resolution of disputes with the parties. For more information, contact the nearest office of the EEOC, DFEH or OCR listed in the telephone directory.

This Policy has been updated with a technical change and supersedes the University of California Policy on Sexual Harassment dated December 14, 2004.

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal. I also realize I am making a serious commitment to volunteer a portion of my time and energies to assist Venice Family Clinic as a volunteer. I further agree to maintain complete confidentiality in respecting the privacy rights of all direct and indirect participants in any Venice Family Clinic activities. I also understand that either party has the option of terminating the relationship for any reason, expressed or not. Name Date

Thank you for completing this volunteer application for the Venice Family Clinic. Please submit this document by pressing the "Submit By E-mail" button at the top of this form. You can also print a copy of this form for your records. Once you have submitted this form and the supporting documentation needed to complete this application, you will be contacted by the Volunteer Services Department.