Annual Volunteer Evaluation

Hospice Austin is required by our accrediting agency (Community Health Accreditation Program) to provide each volunteer with annual education about privacy rights, infection control, and patient rights. Because this is mandatory, in order to continue as an active Hospice Austin volunteer, we must receive this completed form back from you. 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

INFECTION CONTROL

Remember to wash your hands for 20-30 seconds before and after patient contact or use hand sanitizing gels containing at least 60% alcohol. If you are sick, protect yourself and your patients and stay home and rest up.

I have reviewed infection control reminders.*

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.