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Multi-Township EMS Corporation
2304 East Center Street
Telephone: (574) 269-1975 Fax: (574) 269-2340
www. mtems.com
Scott Sigerfoos CCEMT-P, Ad mi nistrator
Multi-Township EMS Volunteer Application
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LCI5 L First Middle Initial
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Address: ::::::
City State zip
Date of Birth: ]E 6SN;
Telephone: :
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Primary Emergenry Contact Information:
Nam€:
TAep'hone: Relationship:
D-fitle Flcense #r EXpiresi.
iNteft'+',: _ Expires:
Natl. RegiStry # rxprres:
Ceftification Level:
Other Ceftifications Expiration Dat€
Eidndtiiis.Va cci n eDEtb TB Vaccine Date
NOTE: Please provide a copy of your current driver's license and EMS ceftification as
well as any other certifications you have.
References: Give the names of three persons not related to you, whom you have known
for at least one year.
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"I certifli that the facts contained
in this application are true and complete to the best of
my knowledge and understand that, if accepted into the volunteer program, falsified
statements on this application shall be grounds for dismissal. I authorize investigation of
all statements contained herein and the references listed above to give you any and all
pertinent information they may have, personal or othenrrrise and release all parties from all
liability for any damage that may result from furnishing same to yorJ".
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MTEMS OBSERVER EVALUATION
FOR ACCEPTANCE INTO VOLUNTEER PROGRAM
NAME LEVHL OF TMINING
DIRECTIONS FOR CANDIDATE: Candidate shallfill in name, date and [evel of training
above and give this form to a medic on duty during shift being observed. Candidate must
be evaluated for 3 shifts before being considered for the volunteer proqram. Candidate
may be required to return for additional shifts if evaluation criteria cannot be met due to
low run volume, etc.
DIRECTIONS FOR STAFF ON DUTY: This evaluation sheet shall be kept confidential. The
evaluating medic may confer with other staff on duty during the shift as to their
observations of candidate. Rate the candidate in the following areas by checking the
appropriate blank.
Out- Above Below Unsatis- Unable to
Behavior around
Behavior at station
COMMENTS
Signature of Medic Date
RETURN THIS FORM TO VOLUNTEER STAFF LIASION OR MANAGING ADMINISTRATOR
ONLY.
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LO-O' MTEMS SKILLS EVALUATION
FOR ACCHPTANCE INTO VOI-UNTHHR PROGRAM
The following skills evaluations may be determined by pedormance on runs or
demonstrated by the volunteer at station.
4&
Oxyqen Equipment
IV Maintenance
IV Placement {ALS onlv)
Cellular Phone
Takinq Vitats
Ainaravs
C-collar application
Communication w/patient
Chartinq
Drivinq
Suction Equipment
Snlintinq
Bandaqing
Radio
Heart monitor
Mast pants
Patient handlinq
Cot
Knowledge of equipment
location on unit
OVEMLL SKILL RANNG
NOTE: NOT ALL OF THE ABOVE SKILLS MUST BE DEMONSTRATED EVERY SHIFT.
PLEASE NOTE BELOW ANY ARFAS THAT NEED IMPROVE]VIENT.
COMMFNTS:
Evaluating Staff Member Date
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Multi-Township EMS Corporation
2304 East Center Street
Telephone: (574) 269-1975 Fax: (574) 269-2340
www.mtems.com
HEPATITIS IM MUNIZATION PROGRAM
Hepatitis B is a viral disease transmitted by blood and body fluids that attack the liver
WITHOUT A KNOWN CURE. Ambulance providers in this area currently require their
EMT's and Paramedics to either obtain the Hepatitis B vaccine or sign a vaccination
refusal form. Please understand that you may be assisting in the Emergency Room
and/or the ambulance. These areas have been designated as areas that personnel are in
a high risk environment for possible exposure to the Hepatitis B virus.
We are requiring each individual to adhere to one of the following:
A. Provide us with proof of previously receiving the Hepatitis B vaccine, or
currently in the process of receiving it.
B. Obtain the vaccine. This is a three-shot regiment given over a period of six
months. You do not need to have the series completed prior to starting, just be
in the process. It is the individual's responsibility to obtain these shots from a
physician.
C. form. FOR YOUR OWN PROTECTION, WE STRONGLY
Sign a vaccine refusal
DISCOURAGE YOU FROM REFUSING TO HAVE THE VACCCINE.
NAME Date
WITNESS Date
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ulti-Townshi P EMS Corporation
M
2304 East Center Street
Telephone: (574) 269-1975 Fax: (574) 269-2340
www,mtems.com
STU DE NT/O BS E RVE R H E PTATIS VACCI NATIO N P ROG RAM
VACCINATION REFUSAL
This is to verify that Multi-Township Emergency Medical Service has informed me of the
potential risks and hazards associated with contracting Hepatitis B. I have chosen not to
obtain the Hepatitis B vaccine at this time,
I realize that during my training/observation I will participate in Ambulance and
Emergency Room procedures. I have been informed and realize that these areas are
designated as high risk and should I be exposed to, or contracL Hepatitis B; I will not
hold Multi-Township Emergenry Medical Service or Kosciusko Community Hospital or any
agents thereof responsible.
I further realize that by participating as a student/observer in no way affiliates me in a
professional matter with Multi-Township Emergency Medical Service and that my
participation is for educational benefit only.
Student/Observer Sig nature Date
Witness Signature Date
MTEMS SKILI-S PROFICIHNCY TESTING
FOR ACCEPTANCE INTO VOLUNTEER PROGMM
ST?FF RECOMMENDATIONS
The volunteer below has completed the required application status or the required 90-day
probationary period of the volunteer program.
Itis essentiat that the volunteer staff demonstrate the ability to perform his or her duties
as an EMT adequatety and professionally. It is also very important that this volunteer and
the MTEMS staff members be able to work together as a team.
The final step in the volunteer acceptance program requires the staff members to
evaluate the votunteer and submit to the Volunteer Coordinator his or her
recommendations for volunteer status.
Upon request, please submit below your recommendations for this volunteer. These
recommendatlons will be considered confidential at all times.
Volunteer Name
Staff Member Date
Do you recommend the above volunteer to be added onto the MTEMS Volunteer Roster:
trYestrNo
Comments:
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I-@-@t
Multi-Township EMS Corporation
2304 East Center Street
Telephone: 97fl 269-1975 Fax (574) 269-2340
www,mtems.com
Personal Injury Waiver Authority For Release of,Information
To: Concerned person or authorized representative of any organization
I, Date of birth
Social Security Number respectfully request and authorize
you to furnish Multi-Township EMS any and all information or records you have
concerning my wor( school, militiary, reputation, all medica[, physical and mental records
or repofts, including all information of a confidential or privileged nature and copies of the
same if requested. This information is to be used to assist Multi-Township EMS in
completing a background history for their confidential use. I hereby release you, your
organization, or others from any liability or damage which may result from furnishing the
information requested.
Must be signed in the presence of Notary
Signature Date
Subscribed and sworn to before me this day of 20
Signature of Notary Public
Notary Public Printed Name
Resident of County Commission Expires
Multi-T ownship Emergency Medical Services
z3o4 East Center Street
Warsaw, lndiana +658o
Telephone: (574) 269-t975 Fax: (574) 269-2340
www.mtems.eono
Scott T. Sigerfoos CCEMT-P, Administrator
Multi-Townsh ip EMS Ride-A-Long Program
A55_U M PTI O=N O F RI SKANDAIABIIry8ELEAS E FO RM
GENERALRLLEASE
, do hereby acknowledge that I have on the
_oay of
o ,2o-t requested to ride in a vehicle owned and
by Multi-Township EMS members or employees in the performance of their
controlled bv N
official duties for the purpose of fur:thering my education in Emergency Medical Services.
-day
fully awar.e of the inherent dangers of riding in an emergency vehicle.
Vehicles, I voluntarily and knowingly assume the risk for any injuries that I may sustain during
the pursuit of my activities while riding in vehicles or while on any of the properties owned or
controlled by Multi-Township EMS. Ifurther, with the intention of binding myself, my spouse,
my heirs, Iegal representatives and assigns, do hereby voluntarily and knowingly remise,
release, and forever discharge and hold harmless Multi-Township EMS, it's officers, members
and employees from actions, suits, damages, claims, or judgments that may result from my
personal injury which I sustain while riding on any Multi-Township EMS vehicle or while upon
any of the properties owned or controlled by Multi-Township EMS.
may be obtained during my ride-a-long and that this information may not be disclosed to
anyone for any reason.
,2O
Releaser: Witness:
Multi-T ownship Emergency Medical Services
z3o4 East Center Street
Warsaw, lndiana 4658o
Telephone: (57Q 269-t975 Fax: (574) 269-2340
www.mqems.eom
Scott T. Sigerfoos CCEMT-P, Administrator
Multi-Township EMS Ride-A-Long Program
The purpose of this guideline is to establish a procedure to be followed for non-members who wish
to ride along in Multi-Township EMS vehicles. This will allow persons interested in joining Multi-
Township EMS as well as persons wishing to study Emergency Medical Services (EMS) an
opportunity for firsthand experience.
The following guidelines shall be followed regarding participation in the Ride-A-Long Program:
THE pARTtCpANT W|LL READ, CHECK AND PLACE THETR INITIALS NEXT TO EACH BOX lF THEY ARE
IN AGREEMENT WITH THESE CONDITIONS!
(All lines must be initialed prior to permission being granted)
Persons wishing to ride-a-long must be at least t8 years of age (unless they can provide a
permission slip from a parent or legal guardian)
Requests for participation shall be directed to Missy )ur er r5er,.
u LU rvlr55y Sorensen.
,,
Participants must sign assumption of risk and liability release form. ,,,
Participants'shall only ride along with crew members. ,:
,:,, ::,, : ," '
Participants slrall not wear any type of clothing which would indicate membership in
another service; they shall dress appropriately and no shorts, or open toed shoes.
Participants shall not become involved in firefighting activities or patient care and must
remain outside incident scene lines unless directed otherwise bv a crew member.
Participants shall wear a seatbelt while in a moving vehicle.
Multi-Township EMS is responsible for the safety and conduct of a participant and may
cancel the ride along session at his or her discretion.
Multi-Township EMS will document a ride along on the run report in the observer
position of the crew listing contained on the patient care record.
Signature: Date:
Printed Name:
Multi -T ow nship Emer gency Me di cal Services
z3o4 East Center Street
Warsaw, Indiana 4658o
Telephone: (574) 269-t975 Fax (574) 269-234o
www,mtems.com
Scott T. Sigerfoos CCEMT-P, Administrator
lnformati
Civen the nature of our work. it is imperative that we maintain the confidence of patient information that we
rece'ive in the course or oLlr work. Multi-Township EMS prohibits the release of any patient information to
anyone outside the department except in limited circumstances and discussions or disclosures of protected
health information (PHl) within the organization should be iimited to the minimum necessary that is needed
forthe recipient of the information to perform their job. Acceptable uses of PHI withinthe organization include
but are not limited to peer review, internal audits, quality assurance and billing. I understand Multi-Township
EMS provides services to patients that are private and confidential and that I am a crucial step in respecting the
privacy rights of Multi-Township EMS patients. I understand that it is necessary, in the rendering of Multi-
Township EMS services, that patients provide personal information and that such information may exist in a
variety of forms such as electronic, oral, written or photographic and that all such information is strictly
confidential and protected by federal and state laws that prohibit its unauthorized use or disclosure.
,
I have received training in the confidentiality policies and procedures set in place by Multi-Township EMS, and
agree I will comply with such policies and procedures during my entire dealings with Multi-Township EMS. lf l,
at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to
notify the Multi-Township EMS HIPAA Privacy Officer Liaison immediately. In addition, I understand that breach
of patient confidentiality or privacy may result in disciplinary action up to and including suspension or
termination of my employment with Multi-Township EMS. Upon separation of my employment for any reason,
or at anytime upon request, I agree to return any and all patient confidential information in my possession.
Ihave read and understand all privacy policies and procedures that have been provided to me by Multi-
Township EMS. I agree to all conditions in this agreement.
Signature: Date:
Printed Name:
M,rlti-To*osLip
Emer6leucr; Medi"al Sewices
Policies I Procedures
Poiicy/Procedure, Privacy and Security of Patient Information
Policy Number: 90,0-35
Purpose: To remain in compiiance u,ith all state and federa-l iau's designed to protect
the privacy, confidentiality, and security of patient information.
Policy:Allpersonnelshallmaintaintheconfidentialit;'ofpatientandotherconfidentia]
informatiorrin accordance with applicable legal and ethical standards and aII MTEMS
Patient Privac;' Policies.
Procedure:
I. Background.
MTEMS and. its personnel are in possession of, and have access to, a
broad variety of confidential, sensitive, and proprietary information.
Inappropriate release of this information could be injurious to
indivicluals, business associates, and MTEMS itself A11 personnel have
an obligation to activeiy protect and safeguard confidential, sensitive, and
proplietary information in a manner" designed to prevent the
unauthorized disclosure of such information.
1. A11 personnel have an obligation to conduct themselves in
accordance with the Health Insurance Portabiiity and
Accountability Act (HIPAA), and MTEMS Policies that have been
enacted to address patient confidentiality. Personnel are advised to
consult appropriate HIPAA Policies or the Privacy Officer for
additional information.
q. There shall be periodic tr"aining on patient privacy issues and a]l
personnel are expected to become familiar with all patient privacy
policies in addition to those contained in the Handbook.
II. Privacy.
A. Infolmation pertaining to a patient's medical situation may generally
only be shared with other health care professionals involved with the
treatment of the patient. Information may also be shared for" other
Iimitecl purposes, such as payment activities and health care operations,
or other purposes specificaJly permitted by lau', in accordance u'ith
MTEMS policies regarding the privacy of patient information'
Page 1 of2
UI. Security.
A' Much of the patient inforr:ration that rne collect is maintainecl on
compllters, and stored and transmitted electronicaliy. In order to
pl'eserve the. integrity of'that data, and protect the confidentiality ancl
security of this patient information, personnel must folloq' all applicable
computer use and data security policies.
W. Privacy/Security Ofiicer.
A. MTEMS has appointed a Privacy/Security Officer who is responsibie for
overall Privacy and Security Policies. If you have any questions about
the use or release of any patient information, you should contact the
Privacv/Securitv Ofiicer.
Effective; Ot/Ol
Revised:
Page2 of2
