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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. Please read and answer the questions below.


  • 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.


  • 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.


  • The most important way to prevent the spread of infection is through meticulous and 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 15 seconds to complete.

    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 through the use of 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 a body fluid, immediately wash or flush the exposed area thoroughly. You should then follow up with the Hospice Austin Employee Health Nurse to determine if any follow up protocols are required. If you have an infection, please refrain from in-person visits for the full duration of your illness.


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

  • 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.


  • 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.


  • 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.