Texas Volunteer Application with Waiver (English)

Volunteer Application Form for Texas

Please complete the following information:
Contact Information
Name:
Phone:
Address:
City, State, Zip:
Address 2:
City, State, ZIP:
Date of Birth:

MonthDayYear
Date
Social Security Number:
Valid Driver’s License:
Email:
example@example.com
Volunteer Position Information:
Have you ever served in the Military?
What Branch in the Military did you serve?
What position are you applying for?
What special skills do you have?
What experience do you have?
What days will you be available?

SunMonTueWedThuFriSat
Education and Work Experience:
Highest Level of Education:
Current Employer:
Personal References:
Reference (1):
Reference (2):
Professional References:
References (1):
References (2):
Availability:

During which hours are you available for Volunteer Assignments?


Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Background Information:


Employer: (If retired please document last employer name)
Occupation:
Employer Address:
Employer Phone Number:

Education and/or Special Skills:
Patient or Family Care:

In-homeNursing HomeHospitalTransportationErrandsRespiteFriendly VisitBedside ChoirBereavement
Non-Patient Services:

ClericalFundraisingMailingsSpecial Events
Please note that a background check and Criminal history check will be conducted if you are in consideration for an opportunity to Volunteer with Tender Care Hospice.
How and where did you learn about our volunteer opportunities? What do you know about Hospice?
Have you ever Volunteered with Tender Care Hospice or any other Organizations before? If so, when?
Do you have reliable transportation?
What makes you want to volunteer with Tender Care Hospice? What do you hope to gain from this experience?
Do you have any fears or concerns about volunteering with someone with a terminal illness?
What are some of your favorite activities and hobbies? Special skills that you may have?
Do you prefer to volunteer working directly with patients (Patient Centered Care or Non- Patient Centered Duties (Administrative?) and why?

Hospice Volunteer Clearance Waiver
By execution of this document, I
hereby acknowledge that I have been informed by Tender Care Home Health & Hospice that a criminal history check will be performed on my name. I have informed this agency of all names (i.e., maiden name, aliases) that I have used in the past. I understand that my volunteer assignment is dependent on background check results.
I hereby profess that I have not been convicted of any of the following crimes which are a permanent automatic bar to volunteering by this agency:
- An offense under Section 19, Penal Code (criminal homicide);
- An offense under Section 20, Penal Code (kidnapping and false imprisonment);
- An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
- An offense under Section 21.08, Penal Code (indecent exposure);
- An offense under Section 21.11, Penal Code (indecency with a child);
- An offense under Section 21.12, Penal Code (improper relationship between educator and student);
- An offense under Section 21.15, Penal Code (improper photography or visual recording);
- An offense under Section 22.011, Penal Code (sexual assault);
- An offense under Section 22.02, Penal Code (aggravated assault);
- An offense under Section 22.021, Penal Code (aggravated sexual assault);
- An offense under Section 22.04, Penal Code (injury to a child, elderly individual or disabled individual);
- An offense under Section 22.041, Penal Code (abandoning or endangering a child);
- An offense under Section 22.05, Penal Code (deadly conduct);
- An offense under Section 22.07, Penal Code (terroristic threat);
- An offense under Section 22.08, Penal Code (aiding suicide);
- An offense under Section 25.031, Penal Code (agreement to abduct from custody);
- An offense under Section 25.08, Penal Code (sale or purchase of a child);
- An offense under Section 28.02, Penal Code (arson);
- An offense under Section 29.02, Penal Code (robbery);
- An offense under Section 29.03, Penal Code (aggravated robbery);
- An offense under Section 33.021, Penal Code (online solicitation of a minor);
- An offense under Section 34.02, Penal Code (money laundering);
- An offense under Section 35A.02, Penal Code (Medicaid fraud); and
- An offense under Section 42.09, Penal Code (cruelty to animals); or
- A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing the elements that are substantially similar to the elements of an offense listed above.
I also hereby profess that I have not been convicted of any of the following crimes within the past 5 years (applicable only to those onboarded on or after September 1, 2007 unless otherwise noted):
- An offense under Section 22.01, Penal Code (assault punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after September 1, 2003];
- An offense under Section 30.02, Penal Code (burglary) [applicable to those hired on or after September 1, 2003];
- An offense under Chapter 31, Penal Code (theft punishable as a felony)[applicable to those hired on or after September 1, 2001]
- An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after September 1, 2003];
- An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or felony) [applicable to those hired on or after September 1, 2003];.
- An offense under Section 37.12, Penal Code (false identification as peace officer); or
- An offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).
Understand that if I have been placed on deferred adjudication community supervision for an offense listed above, successfully completed the period of deferred adjudication community supervision, and received a dismissal and discharge according to Section 5(c), Article 42.12, Code of Criminal Procedure,

I am not considered convicted of that offense.
I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment.I understand that all information obtained by this agency regarding any criminal history will remain confidential.I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.
Signature of Volunteer

Clear
Printed Name
Date

MonthDayYear
Date
Social Security Number
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date

DPS Computerized Criminal History (CCH) Verification

(AGENCY COPY)
I,
acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the volunteer.) Authority for this agency to access an individual's history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.

Once this process is completed the information on my fingerprint criminal history record may be discussed with me.
(This copy must remain on file by this agency. Required for future DPS Audits)
Signature of Volunteer(optional)

Clear
Date

MonthDayYear
Date
Agency Name (Please print)
Signature of Agency Representative

Clear

TEXAS NURSE AIDE REGISTRY &EMPLOYEE MISCONDUCT REGISTRY CHECK FORM
Texas Association for Home Care
3737 Executive Center Drive, Ste. 268
Austin, Texas 78731
(800) 880-880-8893 www.tahc.org
Updated November 15, 2022
Tender Care Home Health & Hospice must determine if an applicant is listed on either the Nurse Aide Registry or the Employee Misconduct Registry, which are maintained by governmental entities of the State of Texas. A person is listed in these registries if the person is found by applicable governmental entities of the State of Texas to have engaged in conduct that is deemed to be abuse, neglect, or financial exploitation of a patient. Persons who are to be listed on the registries have certain rights to contest the finding prior to being listed in the registries. Generally, a covered health care entity may not employ a person if they are listed in one of the registries.
Name of Volunteer:
Last, First, Middle Initial
FOR OFFICE USE ONLY
I,
hereby attest that I personally checked:
1. The Nurse Aide Registry on

MonthDayYear
for the above-named applicant and found that the applicant was was not listed in it.
2. The Employee Misconduct Registry on

MonthDayYear
for the above-named applicant and found that the applicant was was not listed in it.
Signature of employee performing check

Clear
Printed Name

OIG SANCTIONS & EXCLUSIONS CHECK FORM
As a participant in the Medicare program, Tender Care Home Health & Hospice must determine if an applicant is listed on OIG exclusions or sanctions lists. The lists can be accessed at http://www.exclusions.oig.hhs.gov/search.html. A person is listed in these registries if the person is found by applicable governmental entities to have engaged in conduct that results in the person’s exclusion from participation in the Medicare program. Persons who are to be listed in the registries have certain rights to contest the findings prior to being listed in the registries. Generally, a covered health care entity may not employ a person if they are listed in one of the registries.
Name of Volunteer:
Last, First, Middle
FOR OFFICE USE ONLY
I,
hereby attest that I personally checked the OIG exclusions and sanctions list on
Date

MonthDayYear
Agency Representative Name (Please print)
for the above-named applicant and found that the volunteer was was not listed in it, and a copy of the search results are attached to this document.
Signature of Employee Performing Check

Clear
Printed Name
Should be Empty:

Volunteer Application Form for Texas

Hospice Volunteer Clearance Waiver

DPS Computerized Criminal History (CCH) Verification

TEXAS NURSE AIDE REGISTRY &EMPLOYEE MISCONDUCT REGISTRY CHECK FORM

FOR OFFICE USE ONLY

OIG SANCTIONS & EXCLUSIONS CHECK FORM

FOR OFFICE USE ONLY