ÍâÍøÌìÌÃ

Operating Policy and Procedure

HSC OP: 10.28, Volunteers

PURPOSE: The purpose of this HSC OP is to establish requirements for individuals who provide volunteer services at Texas Tech University Health Sciences Center (ÍâÍøÌìÌÃ).

REVIEW: This HSC OP will be reviewed on November 1 of each odd numbered year (ONY) by the campus Volunteer Manager or Director, the Institutional Compliance Officer (ICO), Human Resources International Employment Office, and the Office of General Counsel, with recommendations for revision forwarded to the President for approval.

POLICY/PROCEDURE:

1. Definitions.

a. ÍâÍøÌìÌà Volunteers. ÍâÍøÌìÌà Volunteers are uncompensated individuals who perform services directly related to the business of ÍâÍøÌìÌÃ, support the activities of ÍâÍøÌìÌà or gain experience in specific endeavors at ÍâÍøÌìÌÃ. All volunteer opportunities must be entered into without promise or expectation of compensation, future employment or other tangible benefit. ÍâÍøÌìÌà Volunteers include visiting professors, researchers and/or medical personnel who are not employed by, or do not have faculty appointments at, ÍâÍøÌìÌÃ. Volunteers also include children of faculty or staff performing services on behalf of ÍâÍøÌìÌÃ.

For purposes of compliance under the privacy provisions of the Health Insurance Portability and Accountability Act, ÍâÍøÌìÌà Volunteers are part of the ÍâÍøÌìÌà workforce, but are not considered employees for any purpose and are not covered by the Fair Labor Standards Act. As a result of this volunteer association with ÍâÍøÌìÌÃ, volunteers are not eligible for any ÍâÍøÌìÌà benefits and are not covered by or eligible for Workers’ Compensation. All ÍâÍøÌìÌà Volunteers must be at least 14 years of age. For minors seeking a volunteer assignment longer than 1 day, processing and onboarding should follow HSC OP 70.59, Youth Camps.

For purposes of this policy, ÍâÍøÌìÌà Volunteers do not include the following (this is not an exhaustive list):

1) Individuals acting as members of officially-sanctioned university support organizations;

2) Any individual enrolled at ÍâÍøÌìÌà as a student to earn course credit or to otherwise participate in ÍâÍøÌìÌà academic programs, or who is accepted into a ÍâÍøÌìÌà residency program;

3) Students from other institutions of secondary or higher education who are participating as a part of an officially sanctioned educational agreement with ÍâÍøÌìÌÃ, or are engaged in an educational tour conducted by ÍâÍøÌìÌà staff;

4) Individuals who are visiting fellows;

5) Individuals who seek unpaid academic or research faculty appointments at ÍâÍøÌìÌÃ;

6) Individuals who serve on ÍâÍøÌìÌà Committees as community representative members.

To determine whether an individual should be classified as a ÍâÍøÌìÌà Volunteer, contact the campus Volunteer Manager or Director of Volunteer Services at the campus involved.

b. Volunteer Manager or Director of Volunteer Services. The Volunteer Manager or Director is the individual responsible for selecting, managing, registering and overseeing ÍâÍøÌìÌà Volunteers in accordance with this policy. A Volunteer Manager or Director shall be designated by each campus to oversee the volunteer program.

c. Volunteer Supervisor. The Volunteer Supervisor is the faculty or staff member identified by a School or Department to supervise volunteer services. Each Volunteer Supervisor is responsible for supervising ÍâÍøÌìÌà Volunteers who provide the volunteer service in that School or Department. A Volunteer Supervisor may supervise more than one Volunteer at any given time. To the same extent, one Volunteer may be supervised by more than one faculty or staff member.

2. Selection and Registration of ÍâÍøÌìÌà Volunteers.

a. Authority to Select and Register ÍâÍøÌìÌà Volunteers. Each ÍâÍøÌìÌà Volunteer must be processed and registered by the Volunteer Manager or Director at the applicable campus where the ÍâÍøÌìÌà Volunteers will be providing volunteer services. Faculty and staff DO NOT HAVE THE AUTHORITY to engage or take on Volunteers in the department without approval from the campus Volunteer Manager or Director. Failure to comply with this policy may result in disciplinary action and/or personal liability.

b. Eligibility Requirements of ÍâÍøÌìÌà Volunteers. Persons 14 years or older, including retired employees, students, alumni, and others may submit an application to provide volunteer services to ÍâÍøÌìÌÃ.

1) Volunteers cannot be coerced or pressured, in any way, into volunteering their services.

2) Volunteers must offer their services without any promise, expectation or receipt of compensation for services or future employment.

c. Foreign nationals must have a non-immigrant visa or evidence of lawful presence in the USA in order to engage in volunteer activities. ÍâÍøÌìÌÃ’s International Employment Services Office will review visa status and lawful presence at the request of the Volunteer Services Manager or Director.

1) Foreign nationals and non-immigrant visa holders may only accept reimbursement for actual expenses and may not be paid reasonable benefits or a nominal fee, as this may be considered performing services for compensation and be considered employment;

2) Foreign nationals and non-immigrant visa holders are not allowed to ‘temporarily' volunteer in a position in which they were previously employed, or will be employed, by ÍâÍøÌìÌÃ.

3) If a foreign national’s volunteer activity is expected to last for more than 90 days, ÍâÍøÌìÌÃ’s International Employment Services Office must be contacted.

d. Ineligibility as ÍâÍøÌìÌà Volunteers. The following individuals are not eligible to be Volunteers at or on behalf of ÍâÍøÌìÌÃ:

1) Individuals who were previously dismissed for cause from employment at ÍâÍøÌìÌÃ;

2) ÍâÍøÌìÌà employees whose volunteer services are essentially the same as, or similar to, their regular work at ÍâÍøÌìÌÃ;

3) Foreign nationals who require an export license where the volunteer services involve access to export controlled information or equipment.

d. Observers (also called Shadowing). In the absence of a School or campus policy, this operating policy shall apply to individuals identified by a department or ÍâÍøÌìÌà health care provider for persons who observe or shadow a ÍâÍøÌìÌà health care provider in a ÍâÍøÌìÌà clinic. Those who observe or shadow a health care provider are prohibited from patient care services. Nothing in this operating policy prohibits a School or campus from establishing a separate, written process or procedure to document that individuals who wish to observe or shadow health care providers shall not provide patient care services, and shall receive HIPAA privacy and appropriate safety training prior to initiating observation or shadowing activities.

e. Animal Therapy Program. It is the purpose of the Animal Therapy Program at ÍâÍøÌìÌà to provide positive benefit to the patients. Animal visitation can benefit patients and help to enable the patient to return to wellness. An individual seeking to provide Animal Therapy shall register with the campus Volunteer Manager or Director prior to bringing a therapy animal onto ÍâÍøÌìÌà premises (Attachment G).

f. Graduates from Medical Schools. Medical school graduates in training from medical schools are not be permitted as observers in any of the ÍâÍøÌìÌà GME programs because of the heightened awareness of potential malpractice claims and violation of the Medical Practice Act and licensure rules of the Texas Medical Board. Should programs wish to provide additional training and/or orientation prior to residents’ initial day of residency, the School of Medicine Graduate Medical Education Observers policy will be applicable. Individuals given approval under this operating policy to observe or shadow a health care provider shall not provide patient care services.

g. Application Process. A signed and dated Volunteer Application shall be submitted to the campus Volunteer Manager or Director by each individual seeking to serve as a ÍâÍøÌìÌà Volunteer.

1) Individuals who apply for a Volunteer position and who are 14 to 17 years of age shall complete a Volunteer Application for Minors (Attachment A). The volunteer program allows individuals who are 14 to 17 years of age to provide ÍâÍøÌìÌà with certain low-risk services that do not involve access to electronic confidential information, hazardous or dangerous areas, or use of machinery, etc.

2) Individuals who apply for a Volunteer position and who are 18 years of age or older, shall complete an Adult Volunteer Application (Attachment B).

h. Interview. The campus Volunteer Manager or Director shall interview individuals applying for ÍâÍøÌìÌà Volunteer positions. Interviews may be by phone or in person.

i. Sanction Check. The campus Volunteer Manager or Director shall check individual applicants’ names against the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) located at and the Texas Exclusions Database at . The Volunteer Manager or Director shall promptly notify the ICO if a volunteer applicant is listed on the either Federal or Texas OIG exclusion list. Names of Volunteers at each campus will also be checked monthly against these databases by the ÍâÍøÌìÌà Human Resources Department.

j. Notification. The campus Volunteer Manager or Director shall notify the ÍâÍøÌìÌà Volunteer applicants of their selection (or denial) as ÍâÍøÌìÌà Volunteers.

k. Volunteer Agreement or Parental Consent. Once individuals have been approved to serve as ÍâÍøÌìÌà Volunteers, the campus Volunteer Manager or Director shall obtain the following documents:

1) Volunteer Participation Authorization for Minors (minor consent form) (Attachment C) for individuals 14 to 17 years of age, signed by the volunteer and his or her parent/legal guardian;

2) Voluntary Service Agreement (Attachment D) signed by all Volunteers or, for minors, their parent or guardian;

3) Confidentiality Agreement;

4) Background Check; Necessity for minor background check will be determined by each campus Human Resource office.

5) Safety Training; and

6) Appropriate Vaccinations.

l. Change in Status from ÍâÍøÌìÌà Volunteer to ÍâÍøÌìÌà Employee. In the event of a change in status from a ÍâÍøÌìÌà Volunteer to a paid employee at any Texas government agency, including ÍâÍøÌìÌÃ, no credit, with respect to benefit or retirement programs, will be given to a former ÍâÍøÌìÌà Volunteer for time spent in a volunteer capacity.

3. Responsibilities of ÍâÍøÌìÌà Volunteers.

a. ÍâÍøÌìÌà Volunteers shall comply with all TTU System Regents’ Rules (), ÍâÍøÌìÌà Operating Policies and Procedures (), and applicable federal and state laws and regulations that govern their conduct.

b. ÍâÍøÌìÌà Volunteers shall not:

1) Violate confidentiality regarding protected health information, student information, research information, proprietary information, or other information of a confidential nature acquired through volunteer services and activities;

2) Provide treatment or patient care services to patients including, but not limited to, medical examinations, obtaining patient histories, performing procedures, witnessing documents, unsupervised chaperoning of patients and/or families, providing translation services, or participating in any decision concerning patient care, treatment or management;

3) Write orders in patient charts; give oral health care orders for medical services or medical tests;

4) Obtain patient consent for health care services;

5) Obtain human subjects’ consent;

6) Obligate ÍâÍøÌìÌà financially or suggest or imply that they are acting with the authority of ÍâÍøÌìÌÃ.

c. Confidentiality. ÍâÍøÌìÌà is a public institution of higher education that conducts research and provides educational and health care services, and as such, is governed by federal and state laws regarding confidentiality of patient records, student records, and financial records including, but not limited to, the Family Educational Rights and Privacy Act of 1974, the Health Insurance Portability and Accountability Act of 1996, and the Gramm-Leach-Bliley Act of 1999). ÍâÍøÌìÌà Volunteers shall sign a Confidentiality Agreement in accordance with HSC OP 52.09 agreeing to not access, discuss or disclose confidential information, including but not limited to, patient and/or student information without specific authorization. ÍâÍøÌìÌà Volunteers who violate this confidentiality provision shall be immediately removed from the volunteer program.

d. ÍâÍøÌìÌà Property. ÍâÍøÌìÌà Volunteers are not authorized to have ÍâÍøÌìÌà pagers, voice mail, travel privileges, cell phones, laptop computers or any other privileges associated with being a ÍâÍøÌìÌà employee. ÍâÍøÌìÌà e-mail access is granted only if it is required as part of the service to ÍâÍøÌìÌÃ.

4. Responsibilities of ÍâÍøÌìÌà Campus Volunteer Manager or Director.

a. In-Take. Before ÍâÍøÌìÌà Volunteers can begin providing services at ÍâÍøÌìÌÃ, the following items must be completed.

1) Education and Training. The campus Volunteer Manager or Director is responsible for ensuring that ÍâÍøÌìÌà Volunteers undergo the following education and training:

i. General Volunteer orientation including, but not limited to, a description of the ÍâÍøÌìÌà Volunteers’ duties;

ii. HIPAA Training;

iii. Security Training, if applicable;

iv. Training regarding the Health Surveillance Program for ÍâÍøÌìÌà Institutional Health & Infection Control Program, if applicable - HSC OP 75.11;

v. Safety Training from ÍâÍøÌìÌà Safety Services;

vi. Employment Background Screening as directed by campus Human Resources office Policy - HSC OP 70.20;

vii. Any other training that may be required based on the type of volunteer services to be provided, which shall be determined by the Volunteer Manager or Director.

2) Health Surveillance. Pursuant to HSC OP 75.11, the campus Volunteer Manager or Director shall forward information about each Volunteer to the campus Regional Institutional Personnel Health Unit. The Regional Institutional Personnel Health Unit is responsible for providing written clearance confirmation for each ÍâÍøÌìÌà Volunteer to the campus Volunteer Manager or Director before any Volunteer is allowed to provide direct patient contact services for ÍâÍøÌìÌÃ.

3) Documentation & Verification. The campus Volunteer Manager or Director shall require each Volunteer applicant to acknowledge receipt of the ÍâÍøÌìÌà volunteer requirements which must be fulfilled prior to starting as a volunteer. The Volunteer Manager or Director is responsible for verifying that all requirements are met and then gives final approval or denial.

b. In Processing. The Campus Volunteer Manager or Director shall:

1) Provide the Volunteer Supervisor within the School or Department of ÍâÍøÌìÌà the names of Volunteers who will provide volunteer services;

2) Provide ÍâÍøÌìÌà Volunteers with the names of their Volunteer Supervisor, the start and completion dates of their volunteer service, goals and anticipated activities, and admonitions related to potential areas of security and confidentiality;

3) Process the ÍâÍøÌìÌà Volunteer badge documentation for all non-lab associated volunteers. This shall be done only after successful completion of required training as set forth in this operating policy. All lab volunteers will have badge processed by appropriate lab department administrator or designee.

4) Provide ÍâÍøÌìÌà Safety Services the names of all ÍâÍøÌìÌà Volunteers who will provide services in ÍâÍøÌìÌà laboratories.

c. Termination of ÍâÍøÌìÌà Volunteer Services. Upon termination of a ÍâÍøÌìÌà Volunteer’s services, the campus Volunteer Manager or Director shall:

1) Notify ÍâÍøÌìÌà Safety Services of the date of termination for ÍâÍøÌìÌà Volunteers providing services in laboratories; and

2) Make arrangements for ending services and terminating any privileges granted by ÍâÍøÌìÌà (i.e., return of ID badge, parking);

d. Verification of Volunteer Hours. The campus Volunteer Manager or Director shall document hours provided by ÍâÍøÌìÌà Volunteers as reported by the Volunteers (in the manner determined by the campus). Time served as a Volunteer shall not be included in Visa applications for purposes of showing experience and/or employment history. Non-compliance with reporting of hours donated may be cause for dismissal from either current or future volunteer assignments.

e. Retention of Volunteer Records. The campus Volunteer Manager or Director shall retain all forms, educational and tracking materials pertaining to a ÍâÍøÌìÌà Volunteer for a period of at least three years from the completion date that the ÍâÍøÌìÌà Volunteer completed service.

5. Responsibilities of the Volunteer Supervisor.

a. The Volunteer Supervisor shall complete and sign the Departmental Checklist for Volunteer Orientation (Attachment E), and return it to the campus Volunteer Manager or Director. The departmental checklist is NOT necessary for any volunteer that is scheduled for a rotation less than 2 days. In addition, the Volunteer Supervisor shall provide the following information to ÍâÍøÌìÌà Volunteers:

b. Addition to Research Protocols. The ÍâÍøÌìÌà Volunteer Supervisor must confirm that ÍâÍøÌìÌà Volunteers involved in research projects are properly added to the protocol as approved by the appropriate research oversight committees (e.g., Institutional Review Board, Institutional Biosafety Committee, Institutional Animal Care and Use Committee, Radiation Safety Committee) BEFORE a Volunteer is allowed to participate in the research activity.

c. Evaluations of the ÍâÍøÌìÌà Volunteer. The ÍâÍøÌìÌà Volunteer Supervisor shall provide ongoing informal evaluations of ÍâÍøÌìÌà Volunteers for performance improvement. In addition, the Volunteer Supervisor shall evaluate Volunteers using the Volunteer Competency and Performance Evaluation (Attachment F). All Competency Evaluations shall be forwarded to the campus Volunteer Manager or Director for the School/Regional campus. Any requests for Competency Evaluations or information regarding ÍâÍøÌìÌà Volunteers, such as references, shall be directed to the campus Volunteer Manager or Director.

d. Termination. The Volunteer Supervisor is responsible for terminating any access privileges given to ÍâÍøÌìÌà Volunteers; i.e. IT access; room access.

6. Separation or Termination of ÍâÍøÌìÌà Volunteers. ÍâÍøÌìÌà Volunteers provide services at the sole discretion of ÍâÍøÌìÌÃ. ÍâÍøÌìÌà may, at any time, with or without cause and at its sole discretion, terminate any ÍâÍøÌìÌà Volunteer’s relationship with ÍâÍøÌìÌÃ.

7. Right to Change Policy and or Attachments. ÍâÍøÌìÌà reserves the right to interpret, change, modify, amend or rescind this operating policy in whole or in part at any time without the consent of employees, faculty or students.

Attachment A - Volunteer Application for Minors
Attachment B - Adult Volunteer/Observer Application
Attachment C - Volunteer Participation Authorization for Minors
Attachment D - Volunteer Service Agreement Release, Hold Harmless and Indemnification
Attachment E - Departmental Checklist for Volunteer Orientation
Attachment F - Volunteer Competency and Performance Evaluation
Attachment G - Animal Therapy Program