Microsoft Word - VOLUNTEER PACKET COVER

SUNY UPSTATE MEDICAL STAFF

DISASTER CREDENTIALING PACKET

Thank you for offering to help at Upstate during the current situation! We appreciate the offer of your

skills in caring for our patients. In order to expedite disaster privileges (these expire at the direction of

the hospital or the declaration of the end of the disaster by the hospital), we need to ask you to

complete an abbreviated credentialing process, as outlined below.

Please complete the attached documents:

 Application

 Release

 Orientation

 HIPAA/Confidentiality statement

 Health forms (must be signed by your physician and be accompanied by immunization proofs as

specified on the cover document).

In addition, please provide us with copies of your:

 Curriculum Vitae / Resume (any format)

 driver’s license

 current hospital ID

 current privileges (hospital) or written job description or equivalent (private office or other

healthcare setting)

 vehicle registration (for parking setup)

 photo (for badge)

The above documents may be emailed to [email protected]du

or faxed to 315-464-8524, Attn. : Beth

If you have any questions, please call Beth Erwin, Director, Medical Staff Services & Quality Project

Management at 315-399-9200.

F95114 Review 10/2017

Disaster Credentialing Health Care Professional Form

PLEASE PRINT

NAME: SS#: DOB:

ADDRESS:

CITY:

STATE: ZIP CODE:

HOME PH

ONE: WORK PHONE:

CELL P

HONE: ____________________________ E-MAIL ADDRESS: _____________________________

PRIMARY AFFILIATED HOSPITAL/EMPLOYER & ADDRESS:

SPECIA

LTY BACKGROUND (IE: pediatrics, ICU, emergency dept):

NAME OF

COLLEGE/GRADUATE/MEDICAL SCHOOL or Technical School:

RADTECH

OTHER: __________________

YEAR OF GRADUATION:

CURRENT PROFESSION: MD RN LPN NP PA RT

LICENSE/REGISTRATION/CERTIFICATION #:

STATE OF LICENSURE/REGISTRATION/CERTIFICATION:

Date of Last Clinical Practice Under This License/Registration/Certification:

DEA #

(if applicable)

NPI # ________________________________________________

Epic training: Have you previously used Epic as an Electronic Medical Record (EMR)? YES NO Dates

I certify that the information documented above is true and complete. I understand that misrepresentation or

omission of facts called for may prevent or result in termination of medical staff privileges, if granted. To the

best of my knowledge, I do not have any physical or mental health impairment which is of potential risk to

patients or that might interfere with the performance of my duties, including habituation or addiction to

depressants, stimulants, narcotics, alcohol, or other drugs (including those prescribed) that may adversely

alter my behavior or judgment.

Signature of Professional Requesting Privileges

Date

v Upon conclusion of the emergency, the emergency privileges granted during the emergency situation are

immediately terminated.

v Complete one form for each volunteer.

Approved By (printed name/signature) Date

Labor Pool Unit Leader, Medical Director or Planning Section

Chief/Emergency Incident Commander

F95114 Review 10/2017

UNIVERSITY HOSPITAL

EMERGENCY/DISASTER PRIVILEGES RELEASE

ATTEST THAT THE INFORMATION SUBMITTED BY ME IN THIS APPLICATION IS CORRECT AND COMPLETE.

I hereby volunteer my medical services to University Hospital during this emergency/disaster and agree to practice as directed and

to be bound by all hospital policies and rules as well as the Bylaws, rules and regulations of the Medical/Professional Staff.

I also acknowledge that my emergency/disaster privileges at University Hospital shall immediately terminate once the

ergency/disaster has ended, as notified by the Hospital.

I authorize University Hospital to consult with any individual(s) or organizat

ion(s) who may have information bearing on my

professional qualification, competency, character, mental or emotional stability, physical condition, ethics, behavior or any other

matter bearing on my professional qualifications and competency to carry out the emergency/disaster privileges I am requesting. I

authorize all individuals and organizations who are requested to provide such information to University Hospital or its representative.

I release from any liability all representatives of University Hospital and its Medical/Professional Staff for their acts performed in good

aith and without malice in connection with their evaluation of me and my credentials. I release from any liability all individuals and

organizations who provide information to University Hospital in good faith and without malice concerning my competency, ethics,

character and other qualifications including otherwise privileged or confidential information.

I agree that a photocopy or facsimile of this document with my signature may

be accepted by any entity from which such information

is sought, with the same authority as the original and I specifically waive written notice from any such entities or individuals who may

provide information based upon this authorized request.

I certify that as of this date, I have no physical, medical or mental condition that would impair rendering care to the patients or meeting

edical staff responsibilities. I further attest to having no impairment due to chemical dependency/substance abuse.

Signature of Applicant Date

Printed Name of Applicant

Emergency Management Volunteer (continued) DIS M-25

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Page 9 of 13

Appendix A

Emergency Volunteer Orientation

Upstate EM codes:

Emergency Code Description

Code Red Fire, smoke, or the odor of something burning.

Code Amber Code Amber is activated when an infant/child is confirmed missing.

Code Yellow Bomb Threat has been received or potential explosive device has been

discovered.

Code Black National Weather Service has issued a Severe Weather Watch or a Warning

that potentially endangers the hospital

Code Orange Contaminated patients are presenting to the Emergency Department from

an external Hazardous Materials Spill.

Code White Pediatric Medical Emergency.

Code Blue Adult Medical Emergency.

Code Silver Person with a weapon and/or an individual is being held against their will by

an unarmed/armed perpetrator.

Code Grey An adult patient is missing (Eloped, lost or abducted) from the Hospital.

Code Clear Situation had been resolved.

Imporant Phone Numbers:

• Incident Command: Downtown 464-8888 Community 492-5338

• University Police Downtown 464-4000 Community 492-5511

Fire Safety:

Remember RACE:

• RESCUE or relocate endangered people to a safe place

• ACTIVATE the fire alarm system and call 464-5555 for the Downtown Campus. For leased

properties call 9-911, and for Community Campus call 492- 5011.

o Give fire location

o STAY ON THE PHONE – DO NOT HANG UP

• CONTAIN fire by closing ALL doors and any open windows

o DO NOT turn off oxygen unless told to – note Oxygen Shut Off valves

o Unplug any appliances – touch the cord only – if equipment appears to be overheating/

smoking

• EVACUATE or extinguish

o Evacuate the area as quickly as possible

o Extinguish the flames with extinguisher if trained and the fire has not left its source.

Life Safety:

• INDIVIDUAL RESPONSIBILITIES

o Wear employee identification badge at all times while on Upstate property

o Report unauthorized persons (no ID/badge)

o Report suspicious activities

Emergency Management Volunteer (continued) DIS M-25

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Page 10 of 13

 Include a brief description of suspicious activity

 Include detailed description of person

 Include location

• REPORT ACCIDENTS AND INJURIES

o Involving visitors, students, and employees

Hazardous Materials

Services to be contacted in case of a spill:

o Blood –

 Downtown Campus: Call Environmental Services at 464-6576

 Community Campus: Call Environmental Services at 492-5994

o Chemicals –

 Downtown Campus: Call Environmental Health and Safety at 464-5782

• Nights and weekends: Call University Police Department 464-4000

 Community Campus: Call Environmental Services at 492-5994

o Radioactive Materials –

 Downtown Campus: Call Radiation Safety at 464-6510

 Community Campus: Call Radiology at 492-5015 or 492-5526

o Persons exposed to hazardous spills are to be directed to the Emergency Department

with the applicable Safety Data sheet (SDS)

• Hazardous Material (HAZMAT) spills that cannot be contained require:

o Remove persons from the spill danger and notify others in the area to leave.

o Notify

 Downtown Campus: Call Environmental Health and Safety at 464-5782

 Nights and weekends: Call University Police Department at 464-4000

 Community Campus: Call University Police of the incident at 492-5511 &

Environmental Services at 492-5994 any time

Hand Hygiene

• Upstate University Hospital follows the Centers for Disease Control and Prevention Guideline

for Hand Hygiene in Health-Care Settings

• YOU SHOULD WASH YOUR HANDS

o Before and after giving care to a patient (touching patient or environment)

o Before and after eating

o After removing gloves

o After sneezing, coughing, or using the bathroom

• HAND WASHING SKILL

o Wet hands with warm water

o Apply soap

o Wash hands using friction

o Wash for at least 15 seconds

o Dry thoroughly

• ALCOHOL-BASED WATERLESS HAND SANITIZERS

o Use only if hands are not visibly soiled

o Push one time to get gel/foam into palm of hand

o Rub both hands together using friction till dry

Emergency Management Volunteer (continued) DIS M-25

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• EMPLOYEES WHO ARE REQUIRED TO WEAR GLOVES

o Artificial nails are not acceptable – anything that is not your natural nail

o Nail polish must be in good repair

o Natural nails should be short

o Refer to Hand Hygiene Policy/Procedure (Policy IC D-01/Infection Control Manual)

• THE BLOOD BORNE PATHOGEN STANDARD

o Methods of Compliance:

 Standard Precautions (hand hygiene, use of barriers)

 Engineering and Work Practice Controls (e. g. safety devices, working sinks,

labeling with biohazard symbol or color red to identify contamination and need

for barrier use)

o Personal Protective Equipment - PPE (determine exposure potential; needed barriers)

o Environmental Cleaning (blood spills, decontaminating patient equipment)

• BLOOD-BORNE DISEASES

o You can get a Blood-Borne Disease by:

 Sexual contact

 Women to infant during birth process and breast feeding

 Sharing needles among IV drug users

 Transfusions of infected blood products

 Needle sticks with infected blood

 Infected blood contact to mucus membranes or non-intact skin

• EXPOSURE TO BLOOD/BODY FLUIDS

o Intact skin – (no breaks in skin)- This is not a blood/body fluid exposure

o Non-intact skin – (breaks in skin)

 Wash area with soap and water and report injury

o Needle Sticks and other sharps injuries

 Wash area with soap and water and report injury

o Splashes to mucus membranes of eyes, nose, or mouth

 Flush/rinse area with water and report injury

o Large volume splash – report to Emergency Department for eye irrigation

• REPORT ALL BLOOD/ BODY FLUID EXPOSURES TO YOUR SUPERVISOR/TEAM

LEADER IMMEDIATELY.

STANDARD PRECAUTIONS

• Infection prevention practices are used to protect both the healthcare worker and the patient

• Applies to all patients for handling blood & body fluids, excretions and secretions

• Include the use of hand hygiene and personal protective equipment (PPE)

• Basic Barrier Precautions includes:

o Gloves

o Gowns

o Masks/attached visor

o Protective eyewear

o Use a resuscitation mask/ambu bag if your patient can’t breath

o Sharps and needles are placed in special containers; staff using sharps should:

Emergency Management Volunteer (continued) DIS M-25

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Page 12 of 13

 Avoid using needles or sharps whenever possible

 Use safety devices whenever possible (safety butterflies, safety IV catheters,

safety lancets, etc.)

 Use transfer devices for filling blood tubes directly

 Plan for sharps disposal before starting a procedure

 NEVER recap used needles

• Soiled or dirty linen is placed in a plastic bag for transport to laundry

o Body waste is discarded into hopper or toilet: if chance of splashing, wear eye

protection/masks.

o If soiled with blood/body fluids, reusable equipment is surface wiped down with

hospital-approved germicide wipes and then placed in dirty utility/soiled staging area

for pick-up.

o Spills: wipe up gross material with paper towels, and then clean area with a hospital

approved germicide. Clean spills immediately.

 Wear gloves

 Watch for sharps

o Large spill clean-up:

 Flood large spills with germicide before wiping up

 Downtown- Vocera “housekeeping supervisor” @ 315-464-1400

 Community Campus- call Environmental Services at 315-492-5994

o Empty trash carefully, holding it away from your body, never push trash down with

your hand or foot

HIPAA – Health Insurance Portability and Accounting Act

Access to documents, materials and information containing medical, personal and/or financial

information regarding patients, employees, volunteer or Hospital matters is restricted to those who

need the information to carry out their specific work assignments.

• Unauthorized access to documents or materials and inappropriate use of, discussion of, or

dissemination of such information is consider a breach of confidentiality, and as such is

grounds for dismissal.

• Keep in mind when determining whether you should have access to patient information; use the

“need to know” phrase.

I hereby acknowledge the above conditions of Volunteering Date:_______________

Volunteer’s name__________________________________ Print_____________________

Witnessed By ____________________________________ Print_____________________

UPSTATE MEDICAL UNIVERSITY CONFIDENTIALITY AGREEMENT

Printed Name: ___________________________________ SUNY Employee ID#: ________________

Signature: ___________________________________ Date: __________________________

Employee: _____ Non-Employee: _____ Nursing Service: _____ MedBest _____ Student _____

IMPORTANT: Please read all sections. If you have any questions, please ask before signing.

1. Confidentiality of Patient Information

I understand and acknowledge that: (i) services provided to patients are private and confidential; (ii) to enable

such services to be performed, patients provide personal information with the expectation that it will be kept

confidential and used only by authorized persons as necessary; (iii) all information provided by patients or

regarding services provided to patients, in whatever form such information may exist, including oral, written,

printed, photographic and electronic formats (collectively, the “Confidential Information”) is strictly confidential

and is protected by federal and state laws and regulations that prohibit its unauthorized use or disclosure; and (iv)

in the course of my employment/affiliation with Upstate Medical University (“Upstate”), I may be given access to

certain Confidential Information.

2. Disclosure, Use and Access

I agree that, except as authorized in connection with my assigned duties, I will not at any time use, access or

disclose any Confidential Information to any person (including but not limited to co-workers, friends and

family members). I understand that this obligation remains in full force during the entire term of my

employment/affiliation and continues in effect after such employment/affiliation terminates.

3. User Accounts, Passwords, and Electronic Signatures

I agree that: (i) any unique access codes provided to permit my access to electronic systems will not

be shared with any other individual and shall be kept secure and confidential; (ii) all electronic

transactions are logged and subject to periodic audit; (iii) violation of laws, policies or this

agreement may result in termination of access and other sanctions; and (iv) I certify that affixing my

electronic signature to sign and authenticate electronic documents and entries is my intentional

method of authenticating information and has the same effect as my legal handwritten signature.

4. Return of Confidential Information

Upon the termination of my employment/affiliation for any reason, or at any other time upon request, I agree to

promptly return to Upstate or my employer all copies of business, administrative, and patient confidential

information that is individually identifiable in my possession or control (including all printed and electronic

copies), unless retention is specifically required by law, regulation or for special issues as outlined in the Upstate

University Hospital Administrative Confidentiality Policy.

5. Periodic Certification

I understand that I may be required to periodically certify that I have complied in all respects with this

Agreement, and I agree to so certify when requested.

6. Violations

I understand and acknowledge that: (i) the restrictions and obligations I have accepted under this Agreement are

reasonable and necessary in order to protect the interests of patients, Upstate and my employer (if different from

Upstate); and (ii) I am required to comply with laws and regulations and (iii) my failure to comply with this

agreement in any respect could subject me to penalties by both Upstate as well as third parties. Penalties include

but are not limited to disciplinary measures up to and including termination of employment or affiliation, and the

imposition of civil or criminal penalties.

FM27 REV 10/2018 Oracle Tracker Code: CONFIDAGR

TO:MedicalStaffApplicants

FROM:JarrodBagatell,MD

Director,Employee/StudentHealth

RE:RequirementsforMedicalClearancetobecredentialed



The New York State Department of Health requires:a complete medical history and physical exam, proof of

immunity for rubella and rubeola, and surveillance for tuberculosis be submitted prior to granting

 medical staff

privileges.In addition, evidenceof immunity to mumps, varicella and hepatitis‐B are requiredby Upstatepolicy

and documentation of influenza vaccine for the current influenza season is mandated by the Hospital Executive

Committeeformedicalstafftomaintainprivileges.

RequirementsforMedicalClearance:

 MedicalHistoryand

Physicalexamwithin6monthspriortoanticipatedstartdate

 RubellaIGGAntibodyTiter—evidenceofimmunityby

ONEofthefollowing:

o RubellaIGGAntibodyTiter—(copyofactuallabreportisrequired)

o Documentationofone(1)MMRvaccineonorafter1stbirthday

 RubeolaIGGAntibodyTiter—ifbornon1/1/1957orlater,evidenceofimmunityby

ONEofthefollowing:

o RubeolaIGGAntibodyTiter—(copyofactuallabreportisrequired)

o Documentationoftwo(2)MMRvaccines,oneonorafter1

birthdayandatleast4weeksapart

 MumpsIGGAntibodyTiter—ifbornon1/1/1957orlater,evidenceofimmunityby

ONEofthefollowing:

o MumpsIGGAntibodyTiter—(copyofactuallabreportisrequired)

o Documentationoftwo(2)MMRvaccines,oneonorafter1

birthdayandatleast4weeksapart

 Varicella—evidenceofimmunityby

ONEofthefollowing:

o VaricellaIGGAntibodyTiter—(copyofactuallabreportisrequired)

o Documentationoftwo(2)varicellavaccines,oneonorafter1

birthdayandatleast4weeksapart

 Hepatitis‐BSurfaceAntibodyTiter—ismandatory(copyofactuallabreportisrequired)

o Documentationofthree(3)Hepatitis‐Bvaccinesisalsorequired

 Influenzavaccinationdateforcurrentfluseason(documentationrequired)

 TuberculinSkinTest(PPD)

—within6monthspriortobeginningassignment(priorBCGvaccinationdoes

not negate placing a PPD).IGRA (blood test) for tuberculosis is also acceptable and must be within 6

monthspriortostarting.

 Chestx‐ray—isrequiredifapriortuberculinskintesthasbeenpositive,

thex‐raymustbedonewithin

12monthspriortobeginningassignment.Acopyoftheofficialx‐rayreportisrequired.Youmustalso

submitdetaileddocumentationofthepastpositivePPD.

YourmedicalformsarereviewedonlybythemedicalpersonneloftheEmployee/StudentHealthOffice.Please

submit

allrequireddocumentsatonetimebye‐mail:ESHealth@upstate.eduorfaxto:(315)464‐5471ormailto

theaddresslistedabove.

EMPLOYEE/STUDENT HEALTH

Jacobsen Hall

750 East Adams Street

Syracuse, NY 13210

315-464-4260 (telephone)

315-464-5471

(fax)

Email: ESHealth

state.edu