Covid 19 - Volunteer

COVID-19 VOLUNTEER & AGENCY STAFF

The purpose of this form is to ensure that the individual submitting this application is qualified and licensed to provide care.

I am making an application to assist with an emergency or disaster situation. I am either a volunteer affirming that I am not employed by NYC Health + Hospitals and willing to provide services without the expectation of compensation, or I am an individual that will be providing services via a third-party agency. I authorize the release of any information as may be necessary to enable NYC Health + Hospitals to authorize me to provide services at NYC Health + Hospitals. I understand that NYC Health + Hospitals may obtain information about me through the ServNY system or from any hospital, ambulatory surgery center, physician office, or other entity with which I have privileges or at which I work to verify my credentials, including, but limited to, licensure, criminal background check, etc.

If you have questions about this form or your application, please email CovidVolunteers@nychhc.org.

NOTE FOR NURSES: Nurses should not complete this form; instead, if you are a nurse interested to volunteer with NYC Health + Hospitals, please email Albert at belaroa@nychhc.org.

Thank you for volunteering with NYC Health + Hospitals to help during the COVID-19 outbreak!

Is the number you provided in question 20 a nurse certification number?

No

Yes

Is the number you provided in question 20 above a nurse registration number?

No

Yes

Please list other states in which you hold a License, Certification, or Registration

Emergency Contact Person

Emergency Contact Person Phone

Do you have any special needs or accommodations that need to be addressed?

No

Yes

Are any challenges pending against your license, certification or registration; or has your license, certification or registration ever been refused, revoked, suspended, terminated, relinquished, reprimanded, probated, monitored, limited, investigated, or challenged in any way or otherwise encumbered either voluntarily or involuntarily or while under or in lieu of investigation?

No

Yes

Have you ever been convicted of a crime, felony, or gross misdemeanor, or have any pending charges?

No

Yes

Have you ever been excluded or received sanctions from any state or federal health care program?

No

Yes

Are you free of communicable or contagious disease?

No

Yes

Are you presently experiencing any symptoms or health conditions that may negatively affect your ability to serve at NYC Health + Hospitals?

No

Yes

Are there currently pending challenges against your appointment and/or membership or request for any privileges or scope of practice in any hospital or medical facility, medical organization, society, insurance company, or managed care plan, or has your appointment or membership or request for privileges or scope of practice ever been refused, revoked, suspended, reduced, withdrawn, probated, reprimanded, investigated, challenged, or not reviewed either voluntarily or involuntarily or while under or in lieu of an investigation?

No

Yes

Are there currently pending challenges against your federal or state narcotics license (DEA registration), or has your license ever been refused, revoked, suspended, terminated, relinquished, reprimanded, probated, monitored, limited, investigated, or challenged in any way or otherwise encumbered either voluntarily or involuntarily or while under or in lieu of investigation?

No

Yes

When was the last time you directly cared for patients?

Have you used the Epic electronic health record platform before?

Yes, I feel confident in using Epic

Yes, but I would need some extra training

No

You will need to provide a valid government-issued photo identification issued by a state or federal agency (e.g., driver’s license or passport). Please upload image files only. (Jpeg, Jpg, Png, etc.)

A driver’s license or passport

In addition to the government-issued photo ID, you must provide one of the other four types of identification listed below. Please upload image files only. (Jpeg, Jpg, Png, etc.)

A current picture employer I.D. card that clearly identifies professional/job designation

A current license, certification, or registration to practice

Identification indicating membership on a Disaster Medical Assistance Team (DMAT), Medical Reserve Corps (MRC), Emergency System for the Advance Registration of Volunteer Health Professionals (ESAR-VHP) or other recognized state or federal organization or groups

Identification indicating that I have been granted authority to render patient care, treatment, and services in disaster circumstances (such authority have been granted by a federal, state, or municipal entity)

Have you received a COVID-19 vaccine?

No

Yes

I attest that all above statements are true and accurate

I Attest

I Do Not Attest

I agree to accurately and legibly complete medical records and other documents associated with providing care, as much as is reasonably possible given the exigencies of the situation, and to cooperate with hospital as necessary regarding such care.

I Attest

I Do Not Attest

I attest I have received physical assessment by a qualified medical provider (e.g. a physician, physician assistant or nurse practitioner), performed within the past 12 months prior to assignment.

I Attest

I Do Not Attest

I attest I have received my influenza shot for the current flu season.

I Attest

I Do Not Attest

I attest I have received the Measles, Mumps and Rubella (MMR) vaccine 2 times or am otherwise immune. (For Measles and Mumps you may also check attest if you were born before January 1, 1957 in the USA).

I Attest

I Do Not Attest

I attest I have received Varicella titers. If no, you may still serve at NYC Health + Hospitals.

I Attest

I Do Not Attest

I attest I have received the Hepatitis B vaccine series or are otherwise immune.

I Attest

I Do Not Attest

I attest I have received TB screening via TST implant or via Quantiferon as an alternative, performed within the past 12 months and if positive a chest X-Ray was performed and the results were unremarkable.

I Attest

I Do Not Attest

I attest I do not have a history of a diphtheria/tetanus (dt) or diphtheria, tetanus and pertussis (Tdap) within 10 years prior to the assignment start date.

I Attest

I Do Not Attest

I attest I will produce documentation in support of these statements as soon as possible upon request.

I Attest

I Do Not Attest

I attest that I am in good health, free of habituation or addiction of depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter my behavior.

I Attest

I Do Not Attest

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By clicking the “Submit” button , you are signing this form electronically, and agree the electronic signature is the legal equivalent of your manual signature on this application.