Annual Volunteer Evaluation

Hospice Austin is required by our accrediting agency (C.H.A.P. Community Health Accreditation Program) to provide each volunteer with annual education about HIPPAA, Patient Rights, exposure/Infection Control, TB Screening, and the Medical Devise Act. Because this is mandatory, in order to continue as an active Hospice Austin volunteer, we must receive this completed form back from you. All volunteers are responsible for protecting themselves, patients, and fellow staff from infectious disease. In order to do this and to comply with Hospice Austin Policy, you must be familiar with the following material. Please read and answer the questions below.

Name

First Last

Email

HIPAA

Remember to honor patients’ privacy and keep all information confidential. Don’t share any information about a patient/family with anyone without obtaining permission from your supervisor to ensure that we have appropriate consent. This includes anyone asking how the patient is doing even if they say they know the patient.

I understand my obligation to patients’ privacy under the HIPAA Privacy and Security Rules. If I witness, am involved in, or have any doubt whether patient information has been disclosed inappropriately, I will contact my supervisor immediately.*

Yes
No

PATIENT RIGHTS

Suspected fraud, abuse, neglect, and exploitation- if you have any suspicions that a patient is being abused, neglected, or exploited by anyone (including a Hospice Austin employee or volunteer), you must report your suspicions to the volunteer coordinator immediately.

Suspected Medicare billing fraud or Identity theft- if you suspect fraud of any kind, including Medicare/ Medicaid/ Private Insurance or Identity theft, you must report your suspicions to the volunteer coordinator immediately.

I have reviewed and agree to honor our Patient Rights and understand that I must report any suspicions immediately to my supervisor, Director of Quality or Executive Director.*

Yes
No

EXPOSURE/INFECTION CONTROL

The most important way to prevent the spread of infection is through wearing masks and meticulous, frequent hand hygiene. You should clean your hands before and after you interact with patients, before and after using gloves, after using the restroom, before eating and anytime your hands get soiled. Hand hygiene can be performed with either soap and water or with hand sanitizer. Either method should take at least 20 seconds to complete.

All volunteers should ask patients and their families if they would prefer the volunteer wear a mask during visits. Volunteers should use precautions in any situation when they may interact with blood or body fluids. These precautions involve creating a barrier between themselves and any bodily fluid – the most common way to do that is with masks and gloves. Most patients have gloves available in their homes which have been provided by Hospice Austin. Note that gloves DO NOT replace the need for hand hygiene!

If you are exposed to body fluids, immediately wash or flush the exposed area thoroughly for a full minute. You should then follow up with the Hospice Austin Employee Health Nurse to determine if any follow up protocols are required.

If you exhibit any respiratory symptoms, or any other infectious symptoms (e.g., fever, cough, vomiting, diarrhea, shingles etc.), please inform your supervisor and await instructions from Employee Health before participating in any in-person volunteering. If you have an infection, please refrain from in-person visits for the full duration of your illness.

Flu Vaccine Declination or Proof of Vaccination:
Flu season lasts from September to May. To reduce the spread & severity of flu among patients, staff, and volunteers, the CDC recommends annual flu vaccinations (CDC Influenza Information). Hospice Austin requires EITHER proof of flu vaccination OR a signed declination form for all staff and volunteers.

If you wish to receive a flu vaccination from Hospice Austin, please schedule an appointment with Employee Health by using the link below.

Book time with Simone Oberholzer

Please answer the following questions for the 2024-2025 flu season:*

I decline to receive the flu vaccination, or I’ve received the flu vaccination but do not have proof of paperwork
I have received the flu vaccine between September 2024 and May 2025 and will submit proof to gsmith@hospiceaustin.org

ANNUAL TB SCREENING QUESTIONNAIRE

I understand that Hospice Austin, a healthcare facility, requires TB testing at the time of volunteer training and a TB screening questionnaire annually thereafter.

Have you had temporary or permanent residence or travel for more than 1 month in a country with a high rate of TB (any country other than Australia, Canada, New Zealand, the U.S. or those in western and northern Europe)?*

Yes
No

Have you had close contact with someone who has had infectious TB disease since your last TB test?*

Yes
No

Are you currently or planning to be immunosuppressed?*

Yes
No

This includes:

• HIV infection or receipt of an organ transplant
• Treatment with medications called TNF-alpha antagonists which lower the immune system (e.g., infliximab, etanercept, etc).
• Chronic steroids (equivalent of prednisone 15mg/day for 1 month or more).
• Specialized treatment for rheumatoid arthritis or Crohn’s disease, or other immunosuppressive medications

Persistent cough (> 3 weeks)*

Yes
No

Bloody sputum*

Yes
No

Unexplained fever or persistent fatigue*

Yes
No

Unexplained night sweats*

Yes
No

Unexplained weight loss, or loss of appetite*

Yes
No

Pain in the chest*

Yes
No

Follow-up with a volunteer’s primary physician or the health department will be mandatory for any volunteer identified through the use of the questionnaire to have signs or symptoms of active TB.

I understand that if any of these symptoms occur I should consult my physician and report any active disease to Hospice Austin’s Volunteer Coordinator immediately, as I may be infectious to persons around me.

To the best of my knowledge, the above answers are true and correct.*

Yes
No

SAFE MEDICAL DEVICE ACT

The Safe Medical Device Act of 1990 and the 1995 Final Rule requiring home health care compliance, is a regulation which requires healthcare agencies & facilities to report to the FDA any incident of medical equipment malfunction which results in illness, actual or potential injury or death. The FDA is subsequently responsible for public safety by tracking and even recalling products/devices for further action.

As a volunteer I understand that if I discover equipment malfunction at the residence of a patient I should report that malfunction to the Volunteer Coordinator immediately.

I have reviewed the Safe Medical Device Act.

Yes
No

GENERAL

For the previous year, I believe I have been a consistent and reliable volunteer.*

Yes
No

I submit volunteer time reports for my assignments in a consistent and timely manner.*

Yes
No

I believe I am a good representative of Hospice Austin.*

Yes
No

Additional comments and/or goals for the coming year.

Enter your initials to E-Sign this evaluation.*

By clicking this button, I certify that I am the volunteer named above and that all the information I have entered here is true and correct to the best of my knowledge.