COVID-19 Medical Professional Volunteer Waiver

    Thank you for your dedication to our community, and your willingness to volunteer for Johnson County Hospital District and Johnson County Healthcare Center (JCHC) during this uncertain time. We want to make sure that this volunteer process is as safe and coordinated as possible for everyone involved including medical providers, volunteers, and those patients receiving support. Specifics on protocols regarding your service role will be given to you at the beginning of your first shift.

    We are encouraging any medical professionals who are not at high risk of developing complications from COVID-19, and who are not experiencing any cold or flu-like symptoms, to volunteer in any of the areas listed below:
    - Transportation of supplies
    - Telephone Communication
    - Patient Screening and Evaluation
    - Assisting nursing staff with patient care

    With my signature below, I attest that in the last 14 days I have not:
    -Traveled to, nor come in contact with, someone who has traveled to countries or geographic areas deemed as high risk impacted areas for COVID-19 by the CDC, which include China, Iran, South Korea, Italy, Europe, the UK and Japan.
    -Traveled on a cruise ship.
    -Experienced or are experiencing symptoms of illness.

    I further attest and fully understand that I (“volunteer”) as a volunteer for Johnson County Healthcare Center do hereby and forever release and discharge Johnson County Hospital District, Johnson County Healthcare Center (“JCHC”), and respective board members, officers, employees, agents and volunteers from any and all claims, actions, expenses, liabilities, or damages of any nature whatsoever, including costs and attorney’s fees, arising out of any personal injury, illness, or any loss or damage to property in any way resulting from or otherwise relating to my participation as a JCHC volunteer.

    I fully understand and agree to provide my services to JCHC as a volunteer, and in a volunteer capacity, without financial compensation. JCHC employees may volunteer to serve in a volunteer program such as this, so long as their activities do not directly interfere with their job with JCHC.

    I fully understand that JCHC will not pay for medical treatment for injuries that occur within the scope and course of my volunteer activities. I fully understand that as a volunteer, I do not work for JCHC as an employee, therefore, I am not entitled to workers’ compensation benefits and JCHC cannot provide lost wages or permanent disability benefits for the volunteer’s regular employment.

    I fully understand and agree that if I use my personal vehicle while conducting volunteer activities, my personal automobile insurance is my responsibility and primary to any other insurance that may exist. If asked to volunteer in a capacity that involves the use of my personal vehicle, I agree to provide JCHC with proof of valid insurance prior to assuming any duties as a JCHC volunteer.

    I fully understand and agree that if I use any of my personal property while conducting volunteer activities, that JCHC will not provide insurance coverage or be financially responsible should damage or loss occur.
    I fully understand and agree to sign and abide by, the JCHC HIPPA Confidentiality and NonDisclosure Agreement, which relates to Protected Health Information (“PHI”) and HIPPA requirements.

    By signing this form, I acknowledged that I have read and understood the form, the undersigned is aware of, understands the nature of the JCHC volunteer program, and the participation requirements and conditions, and agrees to the above. I acknowledge and understand that JCHC has exclusive authority to terminate my volunteer participation.

    There truly is no greater contribution that you can make to your community than to assist others in a time of crisis; when others’ needs are urgent, and your aide is lifesaving. Thank you for your service.





    Screening for COVID-19 Volunteers

    Please select any of the following that would place you at a higher risk:
    Currently PregnantChronic Liver or Kidney DiseaseChronic Lung Disease or AsthmaCardiovascular DiseaseHypertensionAge 65+BMI >40DiabetesImmunocompromisedPrimary caregiver for someone with one or more of the above risk factorsPrimary caregiver for a newbornOther: