Ογ½ΆΦ±²₯

Operating Policy and Procedure

HSC OP: 10.28, Volunteers

Attachments

PURPOSE: The purpose of this HSC OP is to establish requirements for individuals who provide volunteer services at Texas Tech University Health Sciences Center (Ογ½ΆΦ±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), the Vice President of Human Resources, and the Office of General Counsel, with recommendations for revision forwarded to the President for approval.

POLICY/PROCEDURE:

1. Definitions.

a. Ογ½ΆΦ±²₯ Volunteers. Ογ½ΆΦ±²₯ Volunteers are uncompensated individuals who perform services directly related to the business of Ογ½ΆΦ±²₯, support the activities of Ογ½ΆΦ±²₯, or gain experience in specific endeavors at Ογ½ΆΦ±²₯. All volunteer opportunities must be entered into without promise or expectation of compensation, future employment, or other tangible benefit. Ογ½ΆΦ±²₯ Volunteers include visiting professors1, researchers, and/or medical personnel who are not employed by, or do not have faculty appointments at, Ογ½ΆΦ±²₯. Volunteers also include children of faculty or staff performing services on behalf of Ογ½ΆΦ±²₯.

For purposes of compliance under the privacy provisions of the Health Insurance Portability and Accountability Act, Ογ½ΆΦ±²₯ Volunteers are part of the Ογ½ΆΦ±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 Ογ½ΆΦ±²₯, volunteers are not eligible for any Ογ½ΆΦ±²₯ benefits and are not covered by or eligible for Workers' Compensation. All Ογ½ΆΦ±²₯ Volunteers must be at least 14 years of age. 2 For minors seeking a volunteer assignment longer than one day, processing and onboarding should follow HSC OP 52.19 Youth Protection Practices. 

For purposes of this policy, Ογ½ΆΦ±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 Ογ½ΆΦ±²₯ as a student to earn course credit or to otherwise participate in Ογ½ΆΦ±²₯ academic programs, or who is accepted into a Ογ½ΆΦ±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 Ογ½ΆΦ±²₯, or are engaged in an educational tour conducted by Ογ½ΆΦ±²₯ staff;

4) Individuals who are visiting fellows;

5) Individuals who seek unpaid academic or research faculty appointments at Ογ½ΆΦ±²₯;

6) Individuals who serve on Ογ½ΆΦ±²₯ Committees as community representative members.

1 This policy does not apply to individuals providing limited educational services, such as conference presenters or guest lecturers outside the laboratory setting.

2 Regarding minors, see also other operating policies including, but not limited to, HSC OP 73.15, Minors in Research Laboratories, and HSC OP 52.19 Youth Protection Practices.

To determine whether an individual should be classified as a Ογ½ΆΦ±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 Ογ½ΆΦ±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 Ογ½ΆΦ±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 Ογ½ΆΦ±²₯ Volunteers.

a.  Authority to Select and Register Ογ½ΆΦ±²₯ Volunteers. Each Ογ½ΆΦ±²₯ Volunteer must be processed and registered by the Volunteer Manager or Director at the applicable campus where the Ογ½ΆΦ±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.

b.  Intent of Volunteers. Volunteers are appreciated, and their assignments and contributions should not be created or assigned to replace, displace, or be in lieu of work typically performed by an employee of the institution. Volunteer duties should not involve ongoing or long-term responsibilities that would otherwise require employment in a paid position. 

c. Eligibility Requirements of Ογ½ΆΦ±²₯ Volunteers. Persons 14 years or older, including retired employees, students, alumni, and others, may submit an application to provide volunteer services to Ογ½ΆΦ±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.

d. Foreign nationals must have a non-immigrant visa or evidence of lawful presence in the USA in order to engage in volunteer activities. Ογ½ΆΦ±²₯'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 Ογ½ΆΦ±²₯.

3) If a foreign national's volunteer activity is expected to last for more than 90 days, Ογ½ΆΦ±²₯'s International Employment Services Office must be contacted.

e. Ineligibility as a Ογ½ΆΦ±²₯ Volunteer. The following individuals are not eligible to be Volunteers at or on behalf of Ογ½ΆΦ±²₯:

1) Individuals who were previously dismissed for cause from employment at Ογ½ΆΦ±²₯;

2) Ογ½ΆΦ±²₯ employees whose volunteer services are essentially the same as, or similar to, their regular work at Ογ½ΆΦ±²₯; and

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

f. 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 Ογ½ΆΦ±²₯ health care provider for persons who observe or shadow a Ογ½ΆΦ±²₯ health care provider in a Ογ½ΆΦ±²₯ clinic. Those who observe or shadow a health care provider are prohibited from providing patient care services. Nothing in this operating policy prohibits a School or campus from establishing a separate, written process or procedure to document the individuals who wish to observe or shadow health care providers shall not provide patient care services, and shall receive appropriate training and clearances equivalent to that of a volunteer prior to initiating observation or shadowing activities.

g. Animal Therapy Program. It is the purpose of the Animal Therapy Program at Ογ½ΆΦ±²₯ to provide positive benefits to the patients. Animal visitation can benefit patients and help 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 Ογ½ΆΦ±²₯ premises (Attachment G).

h. Graduates from Medical Schools. Medical school graduates in training from medical schools are not permitted as observers in any of the Ογ½ΆΦ±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.

i. 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 Ογ½ΆΦ±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 Ογ½ΆΦ±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).

j. 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 . The Volunteer Manager or Director shall promptly notify the ICO if a volunteer applicant is listed on either the Federal or Texas OIG exclusion list. This does not apply to Texas Tech University (TTU) students.

k. Notification. The campus Volunteer Manager or Director shall notify the Ογ½ΆΦ±²₯ Volunteer applicants of their selection (or denial) as Ογ½ΆΦ±²₯ Volunteers.

l. Volunteer Agreement or Parental Consent. Once individuals have been approved to serve as Ογ½ΆΦ±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;. This does not apply to TTU students.

5) Safety Training; and

6) Appropriate Vaccinations

m. Change in Status from Ογ½ΆΦ±²₯ Volunteer to Ογ½ΆΦ±²₯ Employee. In the event of a change in status from a Ογ½ΆΦ±²₯ Volunteer to a paid employee at any Texas government agency, including Ογ½ΆΦ±²₯, no credit, with respect to benefit or retirement programs, will be given to a former Ογ½ΆΦ±²₯ Volunteer for time spent in a volunteer capacity.

3. Responsibilities of Ογ½ΆΦ±²₯ Volunteers.

a. Ογ½ΆΦ±²₯ Volunteers shall comply with all TTU System Regents' Rules (), Ογ½ΆΦ±²₯ Operating Policies and Procedures (http://www.ttuhsc.edu/administration/operating-policies/), and applicable federal and state laws and regulations that govern their conduct.

b.  Ογ½ΆΦ±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 Ογ½ΆΦ±²₯ financially or suggest or imply that they are acting with the authority of Ογ½ΆΦ±²₯.

c. Confidentiality. Ογ½ΆΦ±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. Ογ½ΆΦ±²₯ Volunteers shall sign a Confidentiality Agreement in accordance with HSC OP 52.09, agreeing not to access, discuss, or disclose confidential information, including but not limited to patient and/or student information, without specific authorization. Ογ½ΆΦ±²₯ Volunteers who violate this confidentiality provision shall be immediately removed from the volunteer program.

d. Ογ½ΆΦ±²₯ Property. Ογ½ΆΦ±²₯ Volunteers are not authorized to have Ογ½ΆΦ±²₯ pagers, voice mail, travel privileges, cell phones, laptop computers, or any other privileges associated with being a Ογ½ΆΦ±²₯ employee. Ογ½ΆΦ±²₯ e-mail access is granted only if it is required as part of the service to Ογ½ΆΦ±²₯.

4. Responsibilities of Ογ½ΆΦ±²₯ Campus Volunteer Manager or Director.

a. In-Take. Before Ογ½ΆΦ±²₯ Volunteers can begin providing services at Ογ½ΆΦ±²₯, the following items must be completed.

1) Education and Training. The campus Volunteer Manager or Director is responsible for ensuring that Ογ½ΆΦ±²₯ Volunteers undergo the following education and training:

i. General Volunteer orientation, including, but not limited to, a description of the Ογ½ΆΦ±²₯ Volunteers' duties;

ii. HIPAA Training;

iii. Security Training, if applicable;

iv. Training regarding the Health Surveillance Program for Ογ½ΆΦ±²₯ Institutional Health & Infection Control Program, if applicable - HSC OP 40.01;

v.  Safety Training from Ογ½ΆΦ±²₯ Safety Services

vi. Employment Background Screening as directed by Human Resources 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 40.01, 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 Ογ½ΆΦ±²₯ Volunteer to the campus Volunteer Manager or Director before any Volunteer is allowed to provide direct patient contact services for Ογ½ΆΦ±²₯.

3) Documentation & Verification. The campus Volunteer Manager or Director shall require each Volunteer applicant to acknowledge receipt of the Ογ½ΆΦ±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 giving 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 Ογ½ΆΦ±²₯ the names of Volunteers who will provide volunteer services;

2) Provide Ογ½ΆΦ±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 Ογ½ΆΦ±²₯ Volunteer badge documentation for all non-lab-associated volunteers. This shall be done only after successful completion of the required training as set forth in this operating policy.

All lab volunteers will have their badge processed by the appropriate lab department administrator or designee.

4) Provide Ογ½ΆΦ±²₯ Safety Services the names of all Ογ½ΆΦ±²₯ Volunteers who will provide services in Ογ½ΆΦ±²₯ laboratories.

c. Termination of Ογ½ΆΦ±²₯ Volunteer Services. Upon termination of a Ογ½ΆΦ±²₯ Volunteer's services, the campus Volunteer Manager or Director shall:

1) Notify Ογ½ΆΦ±²₯ Safety Services of the date of termination for Ογ½ΆΦ±²₯ Volunteers providing services in laboratories; and

2) Make arrangements for ending services and terminating any privileges granted by Ογ½ΆΦ±²₯ (i.e., return of ID badge, parking);

3) Verification of Volunteer Hours. The campus Volunteer Manager or Director shall document hours provided by Ογ½ΆΦ±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. 

d. Retention of Volunteer Records. The campus Volunteer Manager or Director shall retain all forms, educational, and tracking materials pertaining to a Ογ½ΆΦ±²₯ Volunteer for a period of at least three years from the completion date that the Ογ½ΆΦ±²₯ Volunteer completed service.

5. Responsibilities of the Volunteer Supervisor.

a. Addition to Research Protocols. The Ογ½ΆΦ±²₯ Volunteer Supervisor must confirm that Ογ½ΆΦ±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.

b. Termination. The Volunteer Supervisor is responsible for terminating any access privileges granted to Ογ½ΆΦ±²₯ volunteers, including IT access and room access.

6. Separation or Termination of Ογ½ΆΦ±²₯ Volunteers.
Ογ½ΆΦ±²₯ Volunteers provide services at the sole discretion of Ογ½ΆΦ±²₯. Ογ½ΆΦ±²₯ may, at any time, with or without cause and at its sole discretion, terminate any Ογ½ΆΦ±²₯ Volunteer's relationship with Ογ½ΆΦ±²₯.

7. Policy Compliance.

Violation of this policy may result in disciplinary action up to and including termination and/or personal liability.

8. Right to Change Policy and or Attachments.
Ογ½ΆΦ±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.

Attachments

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 G - Animal Therapy Program