FVHH Patient Care Volunteer Supervisory Agreement

Patient Name *

I commit to visiting the patient: *

I understand that I will be expected to *

Adhere to the functions and responsibilites outlined in the Patient Care Volunteer position description
Contact this patient and/or family as needed by hospice team and by patient plan of care
Document each contact on a Patient Care Report form through FVHH.NET
Submit the Patient Care Report at least EVERY TWO WEEKS
Contact FVHH immediately with any critial chage to the patient's condition or your availablity to visit patient changes
Schedule and attend all Volunteer Corners required for the year
Adhere to the FVHH code of Confidentiality and the HIPPA privacy Rule. I understand that a breach of confidentiality is grounds for dismissal as a volunteer
Receive annual TB skin test and provide FVHH the results

I understand that I MUST NOT *

I accept the following statements about my volunteer commitments:

I accept the responsibilities as a Patient Care Volunteer and I feel I am able and willing to fufill all of these responsibilities currently
I understand that if I am unable to perform these responsibilties my services as a Patient Care Volunteer may end. Further my volunteer activities may be discontinued by FVHH at their discretion
If at any time and for any reason I feel that I cannot honor my commitment to this patient, I will provide as much advance notice as possible to FVHH to allow for a transition to a new volunteer for my patient.

Name (By typing your name you are agreeing to the above conditions) *

First

Last

Date / Time *