Dear Prospective Member,

Welcome to the Nome Volunteer Ambulance Department (NVAD). Your application will be submitted to the NVAD Officers for consideration by the active membership of the department. Once that process is completed and the members vote you in, you are awarded probationary status. As a probationary member you are afforded the opportunity to become involved in most of the activities of membership. This letter will explain some of the responsibilities, obligations and privileges of NVAD membership.

Probationary status is designed to allow you, the members and Officers of the Department the opportunity to get to know you and to decide if the NVAD is right for you, the Department and our community. The hours can be long, and the working environment can and often is emotionally and physically challenging. You will be afforded the opportunity to participate in on-going emergency medical care, to use the skills you have been taught and are allowed to perform by your certification. You will be required to attend regular meetings of the membership and be allowed to participate in membership activities such as social events and community service projects such as the Christmas toy delivery to needy children.

You will be sponsored by an active member who will agree to act as your sponsor. This is your primary contact during your probationary time. Your sponsor has the responsibilities of providing orientation and training to you and providing information to the general membership and officers on your performance. Your questions should be first directed to your sponsor and if they are unable to help you then to the Training Officer.

You may be issued equipment during this time. This equipment is the property of the Department. You are responsible for it. If a problem develops let your sponsor know.

The probationary period is three (3) months.

As a probationary member you are expected to:

1. Cover all scheduled duty times.2. Run with at least one (1) current EMT.3. Adhere to all policies and procedures of NVAD.4. Complete Probationary Member training checklist

Business meetings are generally held on the first Tuesday of each month with training meetings every other Tuesday. The meeting time is 7:00 pm at the Public Safety Building. The monthly duty roster for each month is updated frequently and emailed out to all the members. Members are expected to sign up for at least 8 shifts per month. Each shift is 12 hours in duration. A member who is on duty is required to respond, when notified, to the garage or scene of a 911 call. As a probationary member it is expected that you will run with an ACTIVE member of the department. An EMT and Driver are considered the minimum crew necessary for a run.

Due to the high visibility of our department within the community, all members are expected to act in a professional manner at all times while on duty when interacting with the public that we serve. NVAD strives to maintain a professional working relationship with professionals of other entities assisting in the care of a patient or the control of the scene.

Members are representing the City of Nome and are expected to follow the chain of command when talking to media, law enforcement, or attorneys’ regarding Department Business. Patient confidentiality is critical and you may not divulge

Updated November 12, 2013

Nome Volunteer Ambulance DepartmentVickie Erickson- NVAD ChiefP.O. Box 281Nome, Alaska 99762Office: (907)443-8522Fax: (907) 443-4109

any run information to anyone who is not directly related to patient care. When in doubt, don’t say anything and contact the NVAD Chief.

Other items you should be receiving are the following:

New Member Orientation LetterNew Driver Orientation LetterNVAD Constitution NVAD Sponsor ChecklistNVAD SOP’sNVAD Treatment Guidelines and Expanded Scope.NVAD HIPPA Policy Form

Should you have any questions please don’t hesitate to ask. There is so much more that you need to know that will only come from running with the department. Our job is to seek information and provide quality patient care.

I certainly hope that you will consider joining the Nome Volunteer Ambulance Department. Being an EMT volunteer is high demand with great rewards and it is not for everyone, but I hope to see and meet with you in the near future.

Should you have any questions on the application process, or want to submit an application, please contact the Emergency Services Office at (907) 443-8522

Sincerely,

Vickie EricksonNVAD Chief

Updated November 12, 2013

NOME VOLUNTEER AMBULANCE DEPARTMENT Application for Membership

Name______________________________________________________________________________________________

Physical Address_____________________________________________________________________________________

Mailing Address_____________________________________________________________________________________

Email: ____________________________________________________________________________________________

Home Phone______________________ Work Phone_____________________ Cell Phone:________________________

DOB ____/____/____ Age______ SSN: _______ - ____ - _______

Employer____________________________________ Occupation______________________________________

If needed, may we contact you at work? Yes _____ No ______

Do you have a valid Alaska Drivers License? Yes_____ No______ License#_____________________

Are you a legal U.S. citizen? Yes____No____

High School Diploma? Yes ____ No ______ GED? Yes _____ No ______

Any College? Some _____ Associates _____ Bachelors ______ Masters +________

Are you certified as an ETT/First Responder? Yes____No____

Are you certified as an EMT? Yes____ No____ Level ______ Certification #:_____________

State in which you are certified___________________________

Are you Nationally Registered ? Yes____ No____ Registration #:______________________

Do you hold any other EMS certificates or medical training? _______________________________________________

Location of training:________________________________________________________________________________

Date of training:____________________________________________________________________________________

Current license/certifications and expiration date:___________________________________________________________

BLS/HCP CPR Certified? Yes_______ No________ Exp. Date:__________________

Please list any ambulance/rescue affiliation and / or hospital experience, etc. you may have in the EMS field.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Updated November 12, 2013

__________________________________________________________________________________________________Other training or certificates

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

In case of an emergency contact:

Name___________________________________________ Relation___________________________

Address___________________________________________________________________

Home Phone_______________________ Cell Phone:_________________ Work Phone_______________________

Allergies: __________________________________________________________________________________________

Any medical history/conditions we should be aware of in the event of an emergency? _____________________________

Yes No

Have you been convicted of a violation of a federal or state law, excluding minor traffic violations, in the last five years?

( ) ( )

Have you ever been convicted of a violation of federal or state law pertaining to medical practice? ( ) ( )

Have you ever been convicted of a violation of federal or state law that pertains to illegal, illicit or prescription drug sales, possession or distribution?

( ) ( )

Have you ever been convicted of either a felony or misdemeanor offense involving domestic violence?

( ) ( )

Have you within the last 10 years been convicted of either a felony or misdemeanor sex offense? ( ) ( )

Have you been convicted of a either a DWI or OMVI in the last 5 years? ( ) ( )

Have you ever been treated for drug addiction or alcoholism? ( ) ( )

Are you currently on federal or state probation or parole? ( ) ( )

I have read and understand the above and certify that the information I have provided is true to the best of my knowledge.

_____________________________ __________________________Signature of Applicant Date

Updated November 12, 2013

I give my permission for the NVAD to conduct a background criminal history and criminal conviction records check.

_____________________________ __________________________Signature of Applicant Date

Requested Sponsor Name:________________________ Requested Sponsor Signature:___________________

*Applicant should attempt to contact an NVAD member for sponsorship. If unable, one will be assigned.

APPLICANT CHECKLIST: (it is the responsibility of the applicant to complete the following items, PRIOR to submitting application for review.)

Driver’s License EMS Certification Background Check Sponsor Signature BLS/HCP Card (if applicable)

REVIEWING OFFICER’S REMARKS:

Officers have received a copy and verified all of the following prior to submitting volunteer for City insurance approval.

Driver’s License EMS Certification Background Check Sponsor Signature BLS/HCP Card (if applicable)

Sponsor Assigned

Approved:_______ Denied:________ Remarks:__________________________________________

_______________________________ ______________ ___________________________ Officer Signature Title Date

*Only COMPELTED and APPROVED applications shall be signed and approved.

Updated November 12, 2013

Nome Volunteer Ambulance DepartmentPolicy on Confidentiality and Dissemination of Patient Health Information

and Staff and Volunteer Member VerificationGiven the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course of our work. NVAD prohibits the release of any patient information to anyone outside the organization unless required for purposes of treatment, payment, or health care operation, and discussions of Protected Health Information (PHI) within the organization would be limited. Acceptable uses of PHI within the organizations include, but are not limited to, exchange of patient information needed for the treatment of the patient, billing, and other essential health care operations, peer review, internal audits and quality assurance activities.

I understand that NVAD provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy rights of NVAD’s patients. I understand that it is necessary, in the rendering of NVAD services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected by federal and state laws.

I agree that I will comply with all confidentiality policies and procedures set in place by NVAD during my entire employment and or association with NVAD. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify the Privacy Officer of NVAD immediately. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my employment or association with NVAD. Upon termination of my employment or association for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. This is not a contract for continued employment or association with NVAD.

I have read and understand all privacy policies and procedures that have been provided to me by NVAD. I agree to abide by all policies or be subject to disciplinary action, which may include verbal or written warning, suspension or termination of employment or association or of any membership with NVAD. This not a contract of employment and does not alter the nature of the existing relationship between NVAD and me.

Signature:_____________________________________ Date: ____________________

Printed Name: _________________________________

Updated November 12, 2013