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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 (Ï㽶ֱ²¥).

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. Ï㽶ֱ²¥ Volunteers. Ï㽶ֱ²¥ Volunteers are uncompensated individuals who perform services directly related to the business of Ï㽶ֱ²¥, support the activities of Ï㽶ֱ²¥ or gain experience in specific endeavors at Ï㽶ֱ²¥. All volunteer opportunities must be entered into without promise or expectation of compensation, future employment or other tangible benefit. Ï㽶ֱ²¥ Volunteers include visiting professors, researchers and/or medical personnel who are not employed by, or do not have faculty appointments at, Ï㽶ֱ²¥. Volunteers also include children of faculty or staff performing services on behalf of Ï㽶ֱ²¥.

For purposes of compliance under the privacy provisions of the Health Insurance Portability and Accountability Act, Ï㽶ֱ²¥ Volunteers are part of the Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥, volunteers are not eligible for any Ï㽶ֱ²¥ benefits and are not covered by or eligible for Workers’ Compensation. All Ï㽶ֱ²¥ 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, Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ as a student to earn course credit or to otherwise participate in Ï㽶ֱ²¥ academic programs, or who is accepted into a Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥, or are engaged in an educational tour conducted by Ï㽶ֱ²¥ staff;

4) Individuals who are visiting fellows;

5) Individuals who seek unpaid academic or research faculty appointments at Ï㽶ֱ²¥;

6) Individuals who serve on Ï㽶ֱ²¥ Committees as community representative members.

To determine whether an individual should be classified as a Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteers.

a. Authority to Select and Register Ï㽶ֱ²¥ Volunteers. Each Ï㽶ֱ²¥ Volunteer must be processed and registered by the Volunteer Manager or Director at the applicable campus where the Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteers. Persons 14 years or older, including retired employees, students, alumni, and others may submit an application to provide volunteer services to Ï㽶ֱ²¥.

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. Ï㽶ֱ²¥â€™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 Ï㽶ֱ²¥.

3) If a foreign national’s volunteer activity is expected to last for more than 90 days, Ï㽶ֱ²¥â€™s International Employment Services Office must be contacted.

d. Ineligibility as Ï㽶ֱ²¥ Volunteers. The following individuals are not eligible to be Volunteers at or on behalf of Ï㽶ֱ²¥:

1) Individuals who were previously dismissed for cause from employment at Ï㽶ֱ²¥;

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

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 Ï㽶ֱ²¥ health care provider for persons who observe or shadow a Ï㽶ֱ²¥ health care provider in a Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Human Resources Department.

j. Notification. The campus Volunteer Manager or Director shall notify the Ï㽶ֱ²¥ Volunteer applicants of their selection (or denial) as Ï㽶ֱ²¥ Volunteers.

k. Volunteer Agreement or Parental Consent. Once individuals have been approved to serve as Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteer to Ï㽶ֱ²¥ Employee. In the event of a change in status from a Ï㽶ֱ²¥ Volunteer to a paid employee at any Texas government agency, including Ï㽶ֱ²¥, no credit, with respect to benefit or retirement programs, will be given to a former Ï㽶ֱ²¥ Volunteer for time spent in a volunteer capacity.

3. Responsibilities of Ï㽶ֱ²¥ Volunteers.

a. Ï㽶ֱ²¥ Volunteers shall comply with all TTU System Regents’ Rules (), Ï㽶ֱ²¥ Operating Policies and Procedures (), and applicable federal and state laws and regulations that govern their conduct.

b. Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ financially or suggest or imply that they are acting with the authority of Ï㽶ֱ²¥.

c. Confidentiality. Ï㽶ֱ²¥ 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). Ï㽶ֱ²¥ 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. Ï㽶ֱ²¥ Volunteers who violate this confidentiality provision shall be immediately removed from the volunteer program.

d. Ï㽶ֱ²¥ Property. Ï㽶ֱ²¥ Volunteers are not authorized to have Ï㽶ֱ²¥ pagers, voice mail, travel privileges, cell phones, laptop computers or any other privileges associated with being a Ï㽶ֱ²¥ employee. Ï㽶ֱ²¥ e-mail access is granted only if it is required as part of the service to Ï㽶ֱ²¥.

4. Responsibilities of Ï㽶ֱ²¥ Campus Volunteer Manager or Director.

a. In-Take. Before Ï㽶ֱ²¥ Volunteers can begin providing services at Ï㽶ֱ²¥, the following items must be completed.

1) Education and Training. The campus Volunteer Manager or Director is responsible for ensuring that Ï㽶ֱ²¥ Volunteers undergo the following education and training:

i. General Volunteer orientation including, but not limited to, a description of the Ï㽶ֱ²¥ Volunteers’ duties;

ii. HIPAA Training;

iii. Security Training, if applicable;

iv. Training regarding the Health Surveillance Program for Ï㽶ֱ²¥ Institutional Health & Infection Control Program, if applicable - HSC OP 75.11;

v. Safety Training from Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteer to the campus Volunteer Manager or Director before any Volunteer is allowed to provide direct patient contact services for Ï㽶ֱ²¥.

3) Documentation & Verification. The campus Volunteer Manager or Director shall require each Volunteer applicant to acknowledge receipt of the Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ the names of Volunteers who will provide volunteer services;

2) Provide Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Safety Services the names of all Ï㽶ֱ²¥ Volunteers who will provide services in Ï㽶ֱ²¥ laboratories.

c. Termination of Ï㽶ֱ²¥ Volunteer Services. Upon termination of a Ï㽶ֱ²¥ Volunteer’s services, the campus Volunteer Manager or Director shall:

1) Notify Ï㽶ֱ²¥ Safety Services of the date of termination for Ï㽶ֱ²¥ Volunteers providing services in laboratories; and

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

d. Verification of Volunteer Hours. The campus Volunteer Manager or Director shall document hours provided by Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteer for a period of at least three years from the completion date that the Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteers:

b. Addition to Research Protocols. The Ï㽶ֱ²¥ Volunteer Supervisor must confirm that Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteer. The Ï㽶ֱ²¥ Volunteer Supervisor shall provide ongoing informal evaluations of Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ 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 Ï㽶ֱ²¥ Volunteers; i.e. IT access; room access.

6. Separation or Termination of Ï㽶ֱ²¥ Volunteers. Ï㽶ֱ²¥ Volunteers provide services at the sole discretion of Ï㽶ֱ²¥. Ï㽶ֱ²¥ may, at any time, with or without cause and at its sole discretion, terminate any Ï㽶ֱ²¥ Volunteer’s relationship with Ï㽶ֱ²¥.

7. Right to Change Policy and or Attachments. Ï㽶ֱ²¥ 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