By signing below, I, the undersigned volunteer, agree to provide services as a volunteer. As a condition of volunteering, I agree as follows:

1. If I am a community volunteer, I understand that I am volunteering my services and I am not entitled to any present or future salary, wages, or other benefits for providing these services. This does not apply to UW Medicine employees who are picking up shifts at a UW Medicine vaccine clinic. UW Medicine employees will be paid the appropriate rate of pay for picking up shifts at a UW Medicine vaccine clinic.

2. I understand that UW Medicine will conduct a criminal background check and that I must provide a valid government-issued photo identification document (driver’s license or passport) and one of the following:

       a. A current picture identification card from a health care organization that clearly identifies professional designation

       b. A current license to practice

       c. Primary source verification of licensure

       d. Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group

       e. Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances

       f. Confirmation by a licensed independent practitioner currently privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster

3. I understand UW Medicine’s expects volunteers to have a positive and supportive attitude towards its patients and staff and will use my best customer service skills while I volunteer.

4. I understand I may be exposed to blood, bodily fluids and other potentially infectious materials that may contribute to the risk of acquiring HIV, Hepatitis B, COVID-19 or other diseases. If I am exposed, or if there is a circumstance where I am the source of an exposure, I will immediately report the incident to the UW Medicine Employee Health Clinic at the facility where I have volunteered.

5. I acknowledge that there are certain risks inherent in participating as a volunteer and will report any incidents and accidents occurring in my assigned volunteer clinic, any work-related illness or injury, and any incidents that could have caused an injury or illness to my assigned supervisor as soon as possible. If I am injured, I will report to the Employee Health Services department or Emergency Department identified by my supervisor immediately for treatment. In the case of emergency, I give my consent for emergency medical treatment and understand that coverage of charges for that treatment being covered by Labor and Industries Insurance is contingent upon proof that I was a volunteer during the time that the emergency occurred.

6. I agree to follow infection prevention requirements for frequent hand washing or use hand sanitizer gel and will wear a mask at all times while I am volunteering.

7. I attest that I have been vaccinated against or have demonstrated immunity to measles, mumps, rubella, tetanus, diphtheria, pertussis, varicella, and influenza. I have also not been exposed to or have symptoms of tuberculosis.

8. I will agree to follow employee health requirements to not volunteer if I have any signs or symptoms of COVID-19 or other respiratory virus syndrome including fever, cough, difficulty breathing, malaise/fatigue, a new rash, unintended weight loss. I have reviewed the CDC COVID-19 symptom list available at click here for CDC symptoms list. I will attest that I have none of these symptoms each time I participate as a volunteer using the tools provided by my supervisor.

UW Medicine volunteers are personally responsible for ensuring the privacy and security of all patient, confidential, restricted, research data, student information or proprietary information to which they are given access (referred throughout as protected information). I also agree as follows:

• I will access, use, and disclose protected information only as allowed by my assigned duties and limit it to the minimum amount necessary to perform my assigned duties. I understand that my access will be monitored to assure appropriate use.

• I will maintain the confidentiality of all protected information to which I have access.

• I will only discuss protected information for reasons related to my assigned tasks and I will not hold discussions where they can be overheard by people who have neither a need-to-know nor the authority to receive the information.

• I will keep protected information out of view of patients, visitors, and individuals who are not involved in the patient’s care.

• I will use UW Medicine resources, including computers, only for my assigned duties or under conditions expressly permitted by UW Medicine.

• I will keep protected information taken offsite fully secured and in my physical possession during transit, never leaving it unattended or in any mode of transport (even if the mode of transport is locked). I will only take protected information off site if expressly approved by UW Medicine.

• I will not access my own protected information, or that of my friends, family members, or other individuals unless it is related to my assigned duties.

• I will protect access to information systems containing protected information:

       o I will commit my password to memory or store it in a secure place;

       o I will not share my password;

       o I will not log on for others or allow others to log on for me; and

       o I will not use my password to provide access or look up information for others without proper authority.

• I am accountable for all accesses made under my login and password, and any activities associated with the use of my access privileges.

• I will only use my own credentials in accessing patient accounts or other systems as provided to me for my assigned duties.

• I will log out or lock computer sessions prior to leaving a computer unattended.

• I will report all concerns about inappropriate access, use, or disclosure of protected information to UW Medicine Compliance (206-543-3098 or comply@uw.edu).

• Failure to comply with these standards may result in an end to my participation as a volunteer.

• My responsibilities involving protected information continue even after my separation from UW Medicine and I understand that it is unlawful for former volunteers to use or disclose protected information for any unauthorized purpose.

My signature below indicates that I have read, accept, and agree to abide by all of the terms and conditions of this Agreement and agree to be bound by it.