Volunteer Questionnaire

Thank you for your interest in becoming a HOOVES Volunteer! In order to connect you with the best area of interest, we have created this survey to get to know you better.
Please read each of the question’s carefully mark the appropriate box or state your answer in the space provided.

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* 1. First Name

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* 2. Last Name

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* 3. Age

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* 4. Gender

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* 5. Email

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* 6. Phone Number

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* 7. Employment Status

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* 8. Have you previously done volunteer work?

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* 9. If yes, what organization(s) have you volunteered with?

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* 10. What projects, tasks and/or activities did you help with?

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* 11. Do you feel these experiences were positive?

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* 12. Are you CURRENTLY involved as a volunteer with any organization?

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* 13. How often are you interested in volunteering?

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* 14. How many hours of time are you willing to commit?

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* 15. What interests you about volunteerism? (Check all that apply)

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* 16. What motivated you to attend the HOOVES Volunteer Training?

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* 17. Please rate, on a scale of 1 being unimportant and 5 being extremely important, your reasons for volunteering.

  1 2 3 4 5
To help others and make a difference
To work with different people
To interact with others and develop relationship with new people
Chance to exercise new skills & abilities
To put something back into the community
To explore different career options/ good on CV
To be a part of a prestigious event
More free time to fill
To gain more practical experience
To do something worthwhile and feel proud
To help the success of the organization
Have a passion for sport

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* 18. What special skills would you like to utilize as a volunteer?

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* 19. Which type of work do you prefer?

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* 20. What are your personal goals for volunteering?

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* 21. What are your 3 greatest strengths?

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* 22. Please select all areas that interest you

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* 23. Of these areas which interests you the most?

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* 24. Are you interested in working towards a leadership role?

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* 25. Are there tasks that you do not want to do as a volunteer?

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* 26. What are your expectations for us as an organization?

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* 27. Is there anything else important for us to know?

VOLUNTEER EXPECTATIONS

The HOOVES Program is primarily run by a volunteer staff. We are incredibly appreciative of
your time and interest in our program! Because we depend so heavily on our volunteers to run
our programming, before accepting someone into our volunteer staff we must make sure that
person is a good fit and able to meet our expectations. We also owe it to you as a volunteer to
clearly communicate these expectations.

Please read the following and initial next to each expectation and sign and date at the bottom.

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* 28. I have read and agree to uphold the HOOVES Code of Conduct.

     - Take responsibility for everything that comes into our experience
     - Refrain from any gossip or slander of group members
     - Uphold the military mindset of selfless service
     - Fill voids through creative thinking and effective application
     - Support each other at any capacity to the best of our ability
     - Strive daily to grow on a personal level
     - Practice what we preach
     - Foster continuous service to humanity
     - Help create a legacy that will continue to serve beyond our lifetime

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* 29. I agree to show up to all events I volunteer for on time and prepared to complete the
task.

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* 30. I understand that each of the following action will result in being terminated as a volunteer:
      - No call/no show to any volunteer event I sign up for
      - Being late for an event more than 2 times
     - Giving less than 24 hours cancellation in non-emergency situations
     - Calling off scheduled duty 2 times

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* 31. HIPAA

HIPAA, Health Insurance Portability and Accountability Act of 1996, relates to the standards for safeguarding the confidentiality of client medical information. All contract staff/volunteers are required to know these standards and comply with the policies of the barn where the contract staff/volunteer works
that pertain to the protection of client medical information. Protected Health Information (PHI), as created and defined by HIPAA, relates to individually identifiable health information that is transmitted in any form or medium. Health information becomes protected when it is combined with any piece of information that could identify the client. Examples of these “identifiers”
include: name of client, all elements of dates, social security number, address and telephone number. A majority of the information obtained during the course of client care would be classified as PHI and therefore should be kept confidential. As a health care worker, you are permitted by HIPAA to use/disclose PHI without the need for specific client authorization to carry out essential healthcare functions for “Treatment, Payment and Health Care Operations.”
     *Treatment means the provision, coordination or management of health care by one or more health care providers, including consultation between health care providers or client referrals.
    *Payment means activities of health care providers to obtain payment or be reimbursed for their services.
    *Health Care Operations include those functions necessary to support core functions of treatment and payment. Examples include quality assessment and improvement activities, training, accreditation, certification, credentialing, licensing, reviewing competence, performance evaluations, business
management and general administrative activities.

All H.O.O.V.E.S staff/volunteers must make reasonable efforts to limit the use or disclosure of, requests for, PHI to minimum amount necessary to accomplish intended purpose. You should communicate only the information that is needed by the person you are communicating with.

HOW TO PROTECT THE PRIVACY OF CLIENT’S PROTECTED HEALTH INFORMATION (PHI)
    * Medical and personal information in the client’s file, or that you have heard, read, or are aware of is
confidential.
    * When someone asks you for information about a client, make sure they have the right to receive the information they are asking for.
    *When you give client information out to others, give only the information the person needs to have.
    *When you need to speak to a staff member about a client’s condition or treatment, you should lower your voice to make sure that the conversation is not overheard by other clients or visitors. Never talk about a client, their illness, treatment, family or situation outside of the barn setting.
    *Never discuss one client with another, even if the clients know each other.
    *Protect client privacy by keeping documents and reports that have PHI on them in safe areas, out of the view of those who might happen to walk by.
    *If you use the telephone, fax machine or email to share PHI with other facilities , organizations or staff/volunteers, make sure that the information you send is going to the correct person and that they have the right to receive the information.

I have read the above HIPAA Compliance Guidelines. As a H.O.O.V.E.S staff/volunteer, I agree to keep confidential any customer or client information that I am exposed to while on assignment. I understand that the breach of this confidentiality will be just cause for immediate removal from active status.

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