EmailMe Form - Medical Professional Volunteer

Name *

Prefix First Last Suffix

Organization (if applicable)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Day Telephone *

### - ### - ####

Mobile Phone

### - ### - ####

Fax

### - ### - ####

Email *

Days Volunteering

Days you are volunteering, check all that apply

Clinic Days: *

Thursday 7/16 (patient registration only)

Friday 7/17

Saturday 7/18

Sunday 7/19

Past RAM® Wise Volunteer *

Yes

No

Past Job Assignments:

Are you coming to participate in this event through:

Lions Club

Student

If student, which college/university?

If student name of preceptor attending

Compliance Statement:

I hereby attest that my license/certificate is not suspended or revoked pursuant to disciplinary proceedings in any jurisdiction. A COPY OF MY CURRENT LICENSE OR CERTIFICATE AND DEA# (where applicable) ARE ATTACHED HERETO. If functioning as a Nurse Practitioner you are required to have a separate practice agreement for this event. Please attach/submit a copy of this agreement

Check box and inital to agree *

I agree (Initial Below)

Confidentiality Statement

I as a professional or general volunteer working at the RAM® event shall maintain the privacy and confidentiality of all information relating to participants in the RAM®; shall not disclose participant information to any third party other than RAM® Headquarters and the Health Wagon, including a volunteer participating in RAM® who does not have a need to know the participant information; shall not use participant information for any purpose except for those related to RAM® event, participant follow-up, and evaluation; and after complying with the obligations set out, shall not retain any participant information, except that RAM®/Health Wagon may retain the names and addresses of participants only to contact them about RAM®/Health Wagon activities. This confidentiality obligation applies even if some or all the participant information may be available from public sources. This pertains to all present and future written and verbal communications referring to any RAM® patient. I also understand that unless I am obtaining information strictly for patient registration or follow-up care, I will not ask a patient any question regarding medical insurance coverage, Medicare, and Medicaid.

Check box and initial to aree *

I Agree (Initial Below)

Release and Indemnification Statement

I hereby release and indemnify Remote Area Medical® and the Health Wagon, non-profit organizations, and all its respective officers, directors, agents, contractors, heirs, successors, and assigns, from prosecution or presentation of any claim for bodily injury or death or for property loss or damage incurred in connection with this Remote Area Medical® expedition or related activities.

Check box and initial to agree *

I Agree (Initial Below)

Professional Information

Profession *

License Number *

State(s) *

If returning volunteer: Describe your specific job assignment performed in the past and what area you worked:

Potential Exposure to Blood Borne Pathogen:

I fully understand that I am volunteering at my own risk and that due to my occupational/other possible exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection or other blood borne pathogens. I agree that if exposed to blood borne pathogens or other potentially infectious materials during the event conducted pursuant to the RAM® event, I will follow the guidelines recommended by the Centers for Disease Control regarding post exposure treatment. I understand that failure to follow the guidelines in the vent of mucous membranes, etc. during the course of work significantly increases chances of infection. Please check and initial one below:

I have received the vaccination for Hepatits B

I Agree (Initial Below)

I have not received the vaccination for Hepatitis B and I am hereby waive having this vaccination of my own free will. I understand if I do not have the HBV vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I want to be vaccinated with Hepatitis B vaccine, I can acquire the vaccination at my own expense and understand that my immunization series should be completed at least 6 months before I plan to volunteer.

I Agree (Initial Below)

Blood Borne Pathogen Training:

Blood borne training is required for all medical and dental volunteers. I hereby certify that I have completed a training/educational program on the risk of exposure to blood borne pathogens and methods to prevent exposure.

Check box and initial to agree

I Agree (Initial Below)

Is the volunteer serving on active duty in the U.S. Armed Services and assigned a duty as practicing commisioned or contract medical officer or dentists at a military hospital or medical facility owned or operated by the U.S. Government? *

Yes

No

Please return copy of current license (if applicable) to:

Health Wagon, POB 7070 Wise, VA 24293, email: wise-ram@thehealthwagon.org, fax: 276-328-8853 Questions, please call 276-328-8850.

Remote Area Medical® is a 501(c) (3) medical relief charity located at 1834 Beech Street, Knoxville, TN 37920