Volunteer Application

GREATER SEACOAST COMMUNITY HEALTH
CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT

I. POLICY
The purpose of this policy is to maintain an adequate level of security to protect the protected health information ("PHI") and personal information of your clients. Staff members include all employees, volunteers, and consultants at Greater Seacoast Community Health. Users who are granted access to protected health information and personal information will be required to sign a Confidentiality and NonDisclosure Agreement. This policy is not intended, and should not be construed, to limit or prevent an employee from exercising rights under the National Labor Relations Act.

II. PROCEDURE
A. Only authorized users are granted access to PHI. Such access is limited to specific, defined, documented and approved applications and level of access rights.
B. As a condition to receiving a username and password, or access rights to PHI (either by electronic or hard copy access), each employee and user must agree in writing to comply with established terms and conditions. Failure to com ply with such terms and conditions may result in the denial and/ or immediate suspension of access to PHI.
C. A violation of the terms of the confidentiality and non-disclosure agreement may be grounds for disciplinary
action, including termination of employment or contract, loss of privileges, legal action for monetary
damages or injunction, or both, or any other remedy available to Greater Seacoast Community Health.

Confidentiality and Non-Disclosure Agreement
Greater Seacoast Community Health's information systems contain confidential records pertaining to business operations, patients, business associate vendors or subcontractors, and Greater Seacoast Community Health employees. Because this information is vital to
the operation of Greater Seacoast Community Health in providing quality service, it must be protected ("protected information"). As such, in accordance with current HIPAA and HITECH regulations, state law and Greater Seacoast Community Health's policies governing the access, use, and disclosure of protected health information, you have the responsibility to protect such data. This
agreement is not intended, and should not be construed, to limit or prevent an employee from exercising rights under the National Labor Relations Act.
The purpose of this agreement is to provide you with information to assist you in understanding your duty and obligations relative to confidential information. Your signature on this document indicates that the information
contained herein has been explained to you, you received a copy of this document, you understand the rules set forth, and that
YOU AGREE:
1. To respect the privacy and confidentiality of any information you may have access to GSCH's computer network and that you will access or use only that information necessary to perform your job.
2. To refrain (whenever possible) from communicating information about a patient or GSCH
  Updated April 2022
  employee in a manner that would allow others to overhear such information and further to refrain from
  discussing a patient's information with anyone not permitted access to such information in accordance with
  GSCH's established policies or that particular patient's wishes (e.g. friends, relatives, visitors, family members or patients, etc.).
3. To disclose confidential patient or staff information ONLY to those authorized to receive it.
4. To safeguard and not disclose your username and password, or any other authorization you may have that allows your access to protected information. You accept responsibility for all entries and actions recorded using your username and password.
5. Not to attempt to learn or use another person's username and password to log-on to GSCH's computer network.
6. To immediately report to the Security Officer any suspicions that your username and password has been compromised.
7. Not to release or disclose the contents of any patient or staff records or reports except to fulfill
  your work assignment.
8. To obtain the approval for use of portable media devices from the Security Officer; to obtain approval to copy any of GSCH's data, exclusive of patient and employee personal information and
  protected health information, to a portable media device from the Security Officer; to maintain the security of data on portable media devices, and to connect portable media devices to a computer secured by the most up to date antivirus software and operating patches as recommended by the Security Officer.
9. Not to sell, loan, alter or destroy any protected information or reports except as properly authorized
  within the scope of your job assignment.
10. Not to leave your computer terminal or workstation unattended without locking or turning off your
  terminal before leaving your work area or securing hardcopy information so that it may not be disclosed to unauthorized persons.
11. Not to access or request any protected information that is not necessary to perform your assigned job function.
12. Not to permit others to access GSCH's computer network using your username and password.
13. To permit your access to GSCH's computer network to be monitored.
14. Not to download or make copies of any software or applications without proper authorization or license.
15. Not to access or download any pornography or other illegal materials or perform any illegal activity such as gambling while on GSCH's computer network.
16. Not to use our agency's computer network to send/forward harassing, insulting, defamatory, obscene, offending or threatening messages.
17. To promptly report any suspected or known unauthorized access, use, or disclosure of protected inform action.
18. To abide by GSCH's "Notice of Privacy Practices," the policies and procedures set forth by GSCH.
  and current federal and state regulations governing privacy issues.
19. To restrict personal use of the agency's computer network to meal and break periods and to follow GSCH's established policies governing such personal use.
20. Not to store personal files or electronic information on GSCH's computer network. Upon termination of my employment or services with GSCH, I shall promptly deliver to GSCH all protected information and documents, including, but not limited to, such things as medical information, emails, notebooks, reports, patient, employee and vendor lists and information, and anything else owned by GSCH or to which GSCH is entitled and which is in my possession or under my control.
Updated April 2022
In the event of a breach or a threatened breach of any of the preceding provisions, GSCH shall, in addition to the remedies provided by law, have the right and remedy to have such provisions specifically enforced by any court having jurisdiction, it being acknowledged and agreed that any breach of any of these provisions will cause irreparable injury to GSCH.

This agreement supersedes and replaces any prior or existing understanding between GSCH and me relating generally to the same subject matter. If any of the above numbered provisions of this agreement is declared void or unenforceable, in whole or in part, by a court of competent jurisdiction, the remainder this agreement or the remainder of such provisions shall remain in full force and effect. If any provision of this agreement is so broad as to be unenforceable, such provision shall be interpreted to be only so broad as to be enforceable.

This agreement shall be governed by and construed in accordance with the laws of the state of New Hampshire. I further understand that the duties and obligations set forth in this document will continue after the termination, expiration, and cancellation of this agreement to include my termination of employment. I also understand my username and password can be temporarily or permanently revoked or I can be terminated if I fail to abide by the rules set forth.
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Printed Name
Signature

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RELEASE

I give Greater Seacoast Community Health the absolute right and permission to publish information and/ or photographs of myself and my children. I give permission for my photograph and/ or information to be:
- Used in Greater Seacoast Community Health publications, such as brochures and annual reports.
- Used by newspapers, magazines and radio and television stations.
- Submitted to organizations that fund Greater Seacoast Community Health for use in their publications.
I agree that all information and photographs will become the exclusive property of

Greater Seacoast Community Health and I waive all rights to them.

I understand that this release does not allow Greater Seacoast Community Health to disclose medical or other personal information about me. It only applies to photographs, videotape and quotations that I write or say about my experiences at Greater Seacoast Community Health.
This Permission applies to:
My name (printed)
My children's names (printed)
Relationship to children (i.e. mother, father, guardian)
Phone number
Address
Signature

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Conflict of Interest Disclosure Form

A potential or actual conflict of interest exists when commitments and obligations are likely to be compromised by the employee's or contractor/ consultant's material interests or relationships (especially economic), particularly if those interests or commitments are not disclosed.

This Conflict of Interest Disclosure Form should indicate whether the employee or contractor/consultant has an economic interest in, or acts as an officer or a director of, any outside entity whose financial interests would reasonably appear to be affected. The employee or contractor/ consultant should disclose any personal, business or volunteer affiliations that may give rise to a real or apparent conflict of interest. Relevant federally and organizationally established regulations and guidelines in financial conflicts must be abided by. Individuals with a conflict of interest will refrain from being involved in any decisions or voting on the potential or actual conflict.

Please describe below any relationships, transactions, or positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest:
I have the following conflict of interest to report (please specify other non-profit and for-profit boards you (and/or your spouse) sit on, any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder, and the name of your employer and any businesses you or a family member own:
I have no conflict of interest to report.I have the following conflict of interest to report (please specify other non-profit and for-profit boards you (and/or your spouse) sit on, any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder, and the name of your employer and any businesses you or a family member own:
1.
2.
I hereby certify that the information set forth above is true and complete to the best of my knowledge.
- I am a volunteer.
Name
Position
Signature

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RELEASE AND WAIVER OF LIABILITY
Name
Address
Phone
Emergency Contact
Phone
I release, and hold harmless Greater Seacoast Community Health (Families First and Goodwin Community Health) from any and all liability claims, and causes of action, of whatever kind or nature (including any injury caused by negligence) incurred in conjunction with the volunteer service.
Signature

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If under 18, parent or guardian must sign here:
Signature of parent/guardian

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GSCH CORPORATE COMPLIANCE PLAN ACKNOWLEDGEMENT

Greater Seacoast Community Health (GSCH) is committed to providing high quality primary health care in a coordinated and responsive manner. In this commitment, we strive to ensure an ethical approach to healthcare delivery and management. We must demonstrate consistently that we act with absolute integrity in the way we provide healthcare and conduct our business.

I, understand that I have the following responsibilities in relationship to my employment at GSCH:

1. Behave ethically in all of my relationships with co-workers, patients and clients, including but not necessarily limited to behaviors outlined in the GSCH Employee Handbook- Values, Ethics and Code of Conduct.

2. Follow the various guidelines, procedures and protocols of:

A.) GSCH Clinical Operations Policies and Procedures Manual, Financial Policies and Procedures Manual, HIPAA Manual, IT Policies & Procedure Manual, WIC Policies and Procedures Manual, and the GSCH Employee Handbook;

B.) Any funding source guidelines (e.g. HRSA, DHHS-NH, etc.) that are pertinent to my role at GSCH;

C.) Any professional licensing or certification requirements, guidelines, etc. which apply to my position within GSCH.

3. Any other guidelines, protocols, procedures, regulations, laws, etc. that apply to my position of business while employed at GSCH.

I will abide by GSCH's Code of Conduct. I acknowledge that I have an obligation as required by Corporate Compliance Standards to report any behavior that appears to violate applicable laws, rules, regulations or the Code of Conduct. I understand that as part of GSCH's Code of Conduct, I may report said behavior without fear of sanction or reprisal. I understand that appropriate channels of reporting include my supervisor, manager, the Compliance Officer, and/or any member of the GSCH Corporate Compliance Committee.

I acknowledge that in the course of my employment or affiliation with GSCH, I have access to paper and/or electronic records, correspondence, reports, and other information/ communications, which by their very nature concern patients, vendors, clients, employees and the general business operations of GSCH. I understand such information is confidential and that I have no right to disclose or disseminate such information in any manner, to any person, unless specifically authorized by a properly executed Authorization to Release Information form under the guidelines of HIPAA Privacy Standards if that information concerns a patient or client, or unless otherwise specifically authorized by applicable law.

This information may include contents of the patient's or client's record, employee information, incident reports, quality improvement reports, computer passwords, and any or all information, electronic records, data, and documents regarding client care provided at GSCH.

I acknowledge that GSCH has informed, cautioned and instructed me that the information concerning patients or clients received by me during the course of my employment or affiliation at GSCH is strictly confidential and is NOT to be disclosed to any unauthorized person or entity no matter what the nature of the information. I fully understand that I may not communicate to other persons or entities, information received in my capacity as an employee, or that might have otherwise come to my attention concerning patients or clients during my employment with GSCH, unless specifically authorized by a properly executed Authorization to Release Information form or as allowed by law or GSCH policy.

I understand that the confidentiality provisions referenced in this document shall survive my termination of employment from or affiliation with GSCH.

I understand that in the event I might disclose any such confidential information without authorization, either intentionally or inadvertently, that I could be legally responsible for breach of confidentiality of such information. Further, I also acknowledge that any willful release of information shall result in immediate disciplinary action up to and including termination of employment or affiliation with GSCH,

I understand that this acknowledgement form is only a clarification of current policies and procedures. I acknowledge that I have received a copy of GSCH's Corporate Compliance Plan, have read it, and understand its contents.
Employee or Agent's Signature

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EMERGENCY NOTIFICATION FORM

Please list the names of individuals we may contact in the event of an emergency.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
EMERGENCY NOTIFICATION FORM

Please list the names of individuals we may contact in the event of an emergency.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Healthcare Provider's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature

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Legal Statement

I, the undersigned, confirm that I have not been convicted of patient abuse, neglect or misappropriation of patient funds or property.
Name

First NameLast Name
Signature

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As an employee, volunteer, consultant, student, contractor, or other individual affiliated with GSCH, please read the foregoing and sign below acknowledging that you understand GSCH's statement of Patient Rights and Responsibilities.

Patients have the right to:
- Receive considerate, respectful, and timely care at GSCH.
- Receive an explanation of their diagnosis, treatment, and prognosis in terms they can understand.
- Receive the necessary information to participate in decisions about their care and to give their informed consent before any diagnostic or therapeutic procedure is performed.
- Expect that their personal privacy will be respected by all staff members at GSCH.
- Expect that their medical records will be kept confidential and will be released only with their written consent, in cases of medical emergencies, or in response to court orders. (Confidentiality can be breached if the individual poses a significant threat of harm to self or others.)
- Know the names and positions of people involved in their care by official nametag or personal introduction.
- Ask and receive an explanation of any charges made by GSCH, even if they are covered by insurance.
- Obtain another medical opinion prior to any procedure.
- Review and receive a copy of any medical records created and maintained by GSCH regarding their care and treatment.
- Effective pain management and to be informed by staff about available measures.
- Be made aware of advance directives, and to know how this organization will respond to such advance directives.
- Care that takes into consideration their psychosocial, spiritual, and cultural values.
Patients are responsible for:
- Providing accurate information about their past health history.
- Asking questions if they do not understand the explanation of their diagnosis, treatment, prognosis, or any instructions.
- Recognizing the effect of their lifestyle on their personal health.
- Providing the necessary information to complete their file and providing updates as information changes.
- Any charges billed to them.
- Following the rules and regulations posted with GSCH and available in the Patient Handbook.
- Providing their practitioner with at least 48 hours’ notice when they or their family are in need of medications or a prescription.
- Arriving on time for their appointments.
- Calling at least 3 hours in advance of their appointment to cancel and/or reschedule.
I have read and understand GSCH's statement of Patient Rights and Responsibilities.
Employee Name

First NameLast Name
Employee Signature

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Greater Seacoast Community Health Property Policy

It is the policy of Greater Seacoast Community Health that prior to termination from employment, all items including but not limited to records, reports, files, resource materials, supplies or equipment that are in the possession of an employee shall be returned to the Center in their entirety. Any and all property is to be returned to the HR Director.

Tangible property such as building keys, identification badges, beepers, cell phones, dictaphones, petty cash, employee AIR funds, etc. as well as proprietary information (e.g., documents, files, work papers, etc.) whether in hard copy form or electronic media are the sole and exclusive property of the Center and must be returned prior to your last day of employment.

I understand that by maintaining in my possession anything that is deemed to be the property of the Center, the Center reserves the right to utilize the avenues available to it to seek the timely return of any such property.

I have read, understand and agree to abide by the terms of this policy.
Employee Name

First NameLast Name
Employee Signature

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Policy and Procedure

Title:	Social Media
Original Date of Implementation:	6/12/2014
Issued By:	Sharlene Poitras, CIO
Written By:	Cathy Smith, Ql Coordinator
Approved By:	Goodwin Community Health Board of Directors
Approval Date:	03/21/2017
Reviewed by Group/Committee:
Review Date(s)	2/10/2017
Revision Date(s)

Background: Widespread use of social media (including blogs, Facebook, Twitter, etc.) has increased the odds of employer involvement in different kinds of claims and litigation related to employees' use of it. Confidential information can very quickly reach a wide audience, and defamatory (or at least inflammatory) statements can spread to the general public very rapidly, given the viral and geometric nature of social networking. In addition, because social networking communication is not limited to the workplace environment or equipment, employees are able to participate in global communications on a 24/7 platform from any public or private locale.

In spite of the risks, Goodwin Community Health (GCH) understands the benefits of employee as well as company sponsored participation in social media.

Purpose: To provide guidelines to GCH employees who participate in social media. Social media includes, but is not limited to, personal blogs and other websites such as Facebook, LinkedIn, Myspace, Twitter, YouTube sites. These guidelines involve protecting the organization and its employees from risky online behavior while not attempting to limit employees' rights to engage in social networking activity. The policy is not intended for internet activities that are purely about personal matters and do not associate or identify an employee with GCH or discuss GCH.

Employees must remember all content contributed on platforms becomes immediately searchable and can be immediately shared. Therefore, employees are responsible for ensuring the appropriateness of oil GCH related content posted by them, regardless of where it is posted.

GCH employees should at all times use social networking in a manner consistent with GCH's mission and values, as well as administrative policies, laws, confidentiality standards, and privacy regulations in order to prevent harm to GCH, its affiliates and the patients they serve.

Policy: When engaging in social networking, all GCH employees should:
1. Abide GCH policies and procedures while participating in online settings. In addition, online actions should not violate any local, state, federal or international laws, or infringe on copyrights or intellectual property rights.
2. Employees must realize their online presence can reflect upon GCH. Whether in the actual world or a virtual one, employees' interactions and discourse must be respectful to themselves and others. For example, patients lose faith in GCH's ability to provide professional, quality healthcare if they see online examples of employees behaving unprofessionally, even on "personal" sites.
3. Protect patient privacy through compliance with all regulations and policies regarding patient information. Employees or volunteers should not post patient photographs, films, x-rays or diagnostic information or disclose any patient identifiers.
4. Confidential or proprietary information and not be posted online. Employees may not reference or cite company clients, partners, vendors, consultants or customers online without their expressed consent.
5. Respect scheduled work time and resources by not using social media during work hours unless in official capacity as a GCH spokesperson. Ensure that social networking does not interfere with your work commitments.
6. Never comment on pending legal matters.
7. Pre-approval must be obtained by GCH Executive Director and Board of Directors before setting up any social networking groups, fan pages, websites or other accounts using the GCH name.
8. GCH logos may not be used without expressed, written consent.
9. Understand that GCH retains the right to monitor Internet communications to the extent necessary to protect its rights or property. In addition, breach of confidential patient health information may also be subject to legal proceedings and/or criminal charges.
10. Everyone is responsible for their actions online whether constructed as entries, comments or replies, and whether posting as an individual or anonymously. Use common sense and act in the best interests of GCH and its affiliates at all times while online. If your blog, posting or other online activities are inconsistent with, or would negatively impact GCH's reputation, employees should not refer to GCH or identify their connection with GCH.
11. Do not provide personal email when acting on behalf of GCH.
I, the undersigned, confirm that I have read and understand the Social Media Policy and Procedure.
Employee Signature

Clear

Medical Documentation Approval Checklist

Overview: The following outlines GSCH’s medical documentation requirements for employees, students, volunteers and any other individuals GSCH deems necessary to provide such documentation.

Purpose: GSCH greatly values the health of all individuals affiliated with GSCH and is therefore committed to complying with public health regulations and preventing the risk of transfer of infection. As such, GSCH requires the following medical documentation for all above listed individuals with periodic review and updating of the information as deemed appropriate by GSCH.

Requirement	Details	Date
Mumps/Measles/Rubella MMR	Proof of Immunization or Evidence of Immunity via TITRE
Hepatitis B Vaccination Series	Proof of Immunization or Consent or Declination Documentation
Varicella	Proof of Immunization or Evidence of Immunity via TITRE or Completion of Questionnaire
PPD Mantoux	Tested within past year or Completion of 2 step
Physical Exam
TDAP	Proof of Immunization within past 10 years
Flu Shot	Proof of Immunization within 12 months
COVID vaccination	“Proof of a completed primary series of the COVID-19 vaccination. A complete primary series is considered either: -Two doses of an mRNA vaccine (Pfizer or Moderna) -One dose of the Janssen/Johnson & Johnson vaccine

Requirement Details Date
Mumps/Measles/Rubella MMR Proof of Immunization or Evidence of Immunity via TITRE
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Hepatitis B Vaccination Series

Proof of Immunization or Consent or Declination Documentation

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Varicella

Proof of Immunization or Evidence of Immunity via TITRE or Completion of Questionnaire

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PPD Mantoux Tested within past year or Completion of 2 step
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MonthDayYear
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Physical Exam

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TDAP Proof of Immunization within past 10 years
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MonthDayYear
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Flu Shot Proof of Immunization within 12 months
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COVID vaccination

“Proof of a completed primary series of the COVID-19 vaccination. A complete primary series is considered either:

Two doses of an mRNA vaccine (Pfizer or Moderna)
One dose of the Janssen/Johnson & Johnson vaccine

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Should be Empty:

Volunteer Application

GREATER SEACOAST COMMUNITY HEALTH