HomeMy WebLinkAboutMINUTES - 05241994 - 1.49 TO: BOARD OF SUPERVISORS }
FROM:' Contra
Finucane, Health Services Director y ` ontra
A By: Elizabeth A. Spooner, Contracts AdministratorCjQsta
DATE: May 9,1994 County
SUBJECT: Approval of Unpaid Student Training Agreement #26-119-2 with
San Jose State University
SPECIFIC REQUESTS) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Health Services Director or his
designee (Frank Puglisi) to execute on behalf of the County,
Unpaid Student Training Agreement #26-119-2 with San Jose State
University, for the period from July 1, 1994 through June 30,
1998, for provision of clinical experience for occupational
therapy students.
II. FINANCIAL IMPACT:
None.
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
On December 10, 1985, the Board of Supervisors approved Unpaid
Student Training Agreement #26-119-1 with the Trustees of the
California State University and Colleges, effective November 1,
1985, and automatically renewed from year-to-year, unless
terminated as set forth in the Agreement, to provide occupational
therapy students from San Jose State University with field
education experience.
Supervised field work experience in occupational therapy is
considered to be an integral part of both educational and profes-
sional preparation. As a teaching hospital, Merrithew can
provide the requisite field education, while at the same time
taking advantage of the students' services to County's patients.
Approval of Unpaid Student Training Agreement #26-119-2 will
update the County's Agreement with San Jose State University and
provide for continuation of this clinical experience opportunity
for the University's occupational therapy students through June
30, 1998 .
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMM ATI NOF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
�L UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
Contact: Frank Puglisi (370-5100) OF SUPERVISORS ON THE DATE SHOWN.
CC: Health Services (Contracts) ATTESTED
Risk Management Phil Batchelor,Clerk of the Board of
Auditor-Controller Suvervisors and County Adm,iristra.tor
Contractor
M382/7-es BY DEPUTY
I. Lt.
t . ._Contra Costa County Standard Form
UNPAID STUDENT TRAINING AGREEMENT
Number 26-119-2
•a
1. Contract Identification.
County Department: Health Services (Hospital and Clinics Division)
Subject: Unpaid student training with Department, sponsored by
Contractor
2 . Parties. The County of Contra Costa, California (County) , for its
Department named above, and the following named Contractor mutually
agree and promise as follows:
Contractor: SAN JOSE STATE UNIVERSITY �u
Capacity: State Educational Institution
Address: 1 Washington Square, San Jose, California 95192-0059
Mailing AddresOccupational Therapy Department, 1 Washington
(�. r Square, San Jose, California 95192-0059
3 . Term. T e ef�fe ive date of this Agreement is July 1, 1994 and
it terminates June 30, 1998 , unless sooner terminated as provided
herein.
4. Termination. This Agreement may be terminated by either party, at its
sole discretion, upon 180 day advance written notice thereof to the
other, or canceled immediately by written mutual consent, subject to
termination conditions (if any) set forth in th ttached
hereto and incorporated herein by reference.
5. Program. By this Agreement County agrees to pe`'mt unpaid student
training by persons (participants) sponsored by Contractor under the
conditions set forth in Paragraph 2. (volunteer Program) of the Program
Plan, attached hereto and incorporated herein by reference.
6. Independent Contractor Status. This Agreement is by and between two
independent contractors and is not intended to and shall not be
construed to create the relationship of agent, servant, employee,
partnership, joint venture, or association.
7 . Indemnification. Except for those activities of participants covered by
the County's
r.�Vcdunteer policy, each party and ,its employees, agents and
offi�ce�s sha�ltrrbe'Findemnified and held harmless against any and all
�!1 ;R+
cla%ms, demands_, orJ causes of action allegediTSZI��-A'
tf ny act or
I .�I \\ 1 I A
,:omission ar �siJ4 as a result of the services p o iagreement,
I i t �.� e �-�
of any officer, agent, or employee of the othe , p air r es t lting from
the conditions of any property owned or controYleo her party.
8. Legal Authority. This Agreement is entered into under and subject to
the following legal authority: California Government Code Sec. 26227.
9. Signatures. These signatures attest the parties' agreement hereto:
COUNTY OF CONTRA COSTA, CALIFORNIA CONTRACTOR
BY BY
Designee
Recommended by Department
(Designate official capacity)
BY
Designee
(Form approved by County Counsel)
Contra Costa County Standard Form
UNPAID STUDENT TRAINING PARTICIPANT AGREEMENT
The County of Contra Costa and the Participant named below agree as follows:
1. Participant will engage in training for a Contra Costa County Department pursuant
to a contract between the County and a contractor sponsoring the participant.
2. Participant agrees that in connection with such training, participant is a
volunteer, subject to the County's volunteer policy and regulations, and will obtain no
employment rights or employment benefits from the County and waives any claim to any
employment rights or benefits from Contra Costa County based upon participant's training
services, whether or not authorized under such contract.
3. Participant further agrees:
"I have read the Resolution adopted by the Contra Costa County Board of
Supervisors on volunteer programs. In return for the benefits provided by Contra Costa
County in case of my illness, injury, death, or third party liability while providing, or
resulting from acts or occurrences within the scope of my authorized volunteer services, and
for my right to authorized expense reimbursement, i waive any claim on my behalf and on
behalf of my heirs, representatives, and assigns against the County of Contra Costa or any
of its agents, servants or employees for illness, injury, debts or other harm arising from
my volunteer services, whether or not authorized. "
4. Participant has read and understands the Unpaid Student Training Agreement
(identified below) between the County and participant's sponsoring contractor and agrees to
and is bound by the terms of that contract.
5. County or participant may terminate this agreement upon three day's notice or
without prior notice, for cause; or by mutual consent; otherwise this agreement terminates
upon termination of the agreement between the County and participant's sponsoring contractor.
6. This agreement is made in consideration of the County accepting participant for
training.
7. Neither the County nor any agent, officer, servant, or employee of the County
shall undertake or incur any liability or other responsibility respecting the quantity,
quality, kind, or value of the training of participant and no warranty, express or implied
shall exist in that regard.
8. This Agreement contains all the terms and conditions agreed upon by the parties.
Except as expressly provided herein, no other- understandings, oral or otherwise, regarding
the subject matter of this Agreement shall be deemed to exist or to bind any of the parties
hereto.
9. Identification of Unpaid Student Training Agreement: Number 26-119-2
Contractor SAN JOSE STATE UNIVERSITY
County Department Health Services Department - Hospital and Clinics Division
CONTRA COSTA COUNTY PARTICIPANT
(Printed Name)
By
(Designee) (Signature)
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE IN OCCUPATIONAL THERAPY
Number: 26-119-2
1. Termination of Prior Agreement. The parties having entered into a
prior Unpaid Student Training Agreement #26-119-1 for the period from
November 1, 1985 and automatically renewed each year until terminated, County
and Contractor hereby agree to terminate Unpaid Student Training Agreement
#26-119-1 and substitute this Agreement #26-119-2 for the aforesaid Unpaid
Student Training Agreement #26-119-1. Effective July 1, 1994, all contract
rights and obligations of the parties will be governed by this Unpaid Student
Training Agreement #26-119-2.
2 . Volunteer Program. By this Agreement, County agrees to permit
unpaid student training by persons (participants) sponsored by Contractor
under the following conditions:
a. Services provided under this Agreement are volunteer services,
and participants obtain no employment rights with, or employment benefits
from, the County, by virtue of this Agreement or service hereunder. County's
unpaid Student Training Participant Agreement, attached hereto and
incorporated herein by reference, is required of every participant.
b. Upon approval by County's Board of Supervisors this Agreement
shall be an authorized volunteer program. The County's volunteer policy and
the County Administrator's rules and procedures for authorized volunteer
programs, attached hereto, are applicable with respect to this Agreement, and
are incorporated herein by reference together with any amendments thereto,
subject nevertheless to the terms of this Agreement.
3 . Purpose of the Program. San Jose State University conducts a
student training program to provide clinical experience for its students
enrolled in the Occupational Therapy Program, in cooperation with County's
Department. The Contractor desires to have students, enrolled in this
Program, receive occupational therapy instruction from the County, and the
County is willing to provide such instruction under the terms and conditions
hereinafter set forth. Therefore, the parties will undertake a program
whereby such instruction and experience will be provided in accordance with
the plan mutually agreed to by the parties.
4. Contractor's Obligations. In participating in this program,
Contractor shall:
a. Assign a staff member to represent Contractor and act as
liaison with County Department in all matters relating to this Agreement.
b. Cooperate with County's Department in establishing assignment
schedules consisting of specific dates for the placement of a specific number
of students with the County for clinical training, which shall be established
by mutual agreement of the respective representatives of the County and
Contractor.
Initials:
Contractor County Dept.
1
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE IN OCCUPATIONAL THERAPY
Number: 26-119-2
C. Assign for such training only those students who are prepared
therefor to a degree considered adequate by mutual agreement of the County
and Contractor.
d. Assign training instructor-supervisors from its School to
supervise their students at each clinical training site and to be responsible
for each student's training program.
e. Make all necessary arrangements with such students, so that
each will:
(1) Have completed or be in good standing for all the
necessary course work required by the Contractor as preparation for placement
in the student training program;
(2) Agree to execute the County's Unpaid Student Training
Participant Agreement upon referral to the training program;
(3) Have transportation to and from County's training sites.
(4) Refer educational problems to the appropriate
instructor(s) in Contractor's School.
(5) Comply with the standards of conduct and the County,
State, and Federal regulations governing professional personnel at County's
clinical training site.
f. Be responsible for the educational program of students
assigned to training with the County; for the selection, evaluation, and
assignment of students in accordance with agreed-upon schedules; and for the
proper conduct of its students and staff in the student training program.
g. Withdraw from the program any student whose performance is
unfit or whose conduct prevents constructive relationships at the clinical
training site, upon the written and suitably documented request from County's
Department.
h. Provide satisfactory assurance or evidence of acceptable
health levels of assigned students.
5. County's Obligations. In participating in this program, County
shall:
a. Assign a staff member from its Department to represent the
County and act as a liaison with Contractor's School in all matters relating
to this Agreement;
Initials:
Contractor County Dept.
2
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE IN OCCUPATIONAL THERAPY
Number: 26-119-2
b. Accept the placement of such students in training as may be
assigned by Contractor in assignment schedules and for a training period as
shall be established by mutual agreement of the respective representatives of
the County and Contractor;
C. Cooperatively, with College District's instructor, provide
each student with clinical training duties consisting of learning experiences
and professional duties needed to accomplish the educational objectives of
Contractor's student training program consistent with the operational
responsibilities and professional activities of County's Department and the
specific clinical training related thereto;
d. Retain responsibility for staffing, quality of occupational
therapy and related duties when students and or occupational therapy
personnel from outside sources are providing care to County's patients.
6. Joint Obligations. County and Contractor shall jointly:
a. Plan a student training program, including course content and
student assignment schedule, so as to provide a sound and effective
educational program; and
b. Review the program at the end of each training period in order
to- evaluate progress and recommend changes for the next consecutive training
period.
7. Student's Obligations. Participants shall:
a. Dress according to college and hospital regulations.
b. Behave in an appropriate, professional manner while in the
clinical area or on the hospital grounds.
C. Arrive in the clinical area on time and return from scheduled
breaks promptly.
d. Establish effective communications with County's medical
personnel.
e. Report to instructor and team leader before beginning
occupational therapy.
f. Notify staff of any significant problems in patient care
and/or changes in his/her patient's condition.
g. Notify appropriate staff member before leaving clinical area.
Initials:
Contractor County Dept.
3
PROGRAM PLAN
FOR
CLINICAL EXPERIENCE IN OCCUPATIONAL THERAPY
Number: 26-119-2
h. Report to appropriate team leader and/or therapy staff orally
and/or in writing as to the condition of assigned patients at end of clinical
day.
i. Abide by hospital and ward regulations as applicable to
students.
j . Ask assistance from instructor while still learning a skill
and seek instruction and guidance, as needed, in clinical assignments, and
not attempt any procedure which is beyond his/her capabilities. Each student
must be checked out by the instructor before attempting a procedure alone.
Student will take responsibility for own actions in carrying out clinical
assignments.
k. Give medications with supervision.
1. Do necessary charting according to hospital policy.
M. Maintain physical and emotional health at a level adequate to
performance of clinical assignments.
n. Avoid abuse of drugs and alcohol.
o. Comply with applicable County, State and Federal regulations
respecting disclosure of patients' health information and access to, and
removal of, medical records and/or information contained therein.
8. Contractor, County and Participant Agreement. Notwithstanding the
authorization for reimbursement for actual and necessary expenses (including
a flat mileage rate of $0. 15 per mile for use of personal vehicles) of
authorized volunteer services set forth in the final paragraph of attached
Contra Costa County Policy Statement on Volunteers, participant shall be
entitled to no reimbursement by County for said expenses while engaged in the
training program covered by this Agreement.
Initials:
Contractor County Dept.
4
CONTRA COSTA COUNTY
POLICY STATEMENT ON VOLUNTEER PROGRAMS
The use of volunteers in performing specific services is a valuable resource
and provides an avenue for citizen participation in various County programs
which is recognized as being of public benefit. In recognition of the
benefits which may be derived from volunteer services, it is hereby declared
that it shall be County policy to encourage and promote volunteer programs
determined to be in the public interest.
It is County policy that volunteers will not replace County employees but
will provide services to supplement or enrich regular County programs and
services.
This policy statement is designed to provide the framework for all County
volunteer programs and activities. The following guidelines are adopted for
volunteer programs:
VOLUNTEER PROGRAMS
A complete description of each volunteer program shall be submitted by the
department head to the County Administrator for review and presentation to
the Board of Supervisors with his recommendation.
Factors to be considered in evaluating programs are the need for and public
benefit to be derived from the volunteer.program, associated County cost and
staff effort required for such a program, the potential for injury to
volunteers, and the possibility for injury to others including injuries
giving rise to possible liability claims.
Regulations and procedures including, but not limited to, such matters as
eligibility, training, supervision and roster control, may be promulgated by
the County Administrator for guidance of departments to assure proper
administration and control of volunteer services.
VOLUNTEERS
A volunteer is defined as a person who renders services gratuitously and has
been accepted in the volunteer program. The volunteer is not an employee of
the County.
In recognition of the benefit to the County derived from volunteer services,
authorized volunteers serving in programs approved by the Board of
Supervisors shall be provided the benefits indicated below.
1
CONTRA COSTA COUNTY
POLICY STATEMENT ON VOLUNTEER PROGRAMS
1. Injury to Volunteer. Authorized volunteers are not under the
purview of the workers' compensation laws of California. In lieu thereof and
in return for the volunteers waiver of any claim against the County for
illness, injury or other harm arising from acts or occurrences while
providing volunteer services, the County shall provide, in the case of
authorized volunteer services, through self-insurance, for reimbursement of
medical expenses and minimum permanent disability compensation equal to that
afforded under the workers' compensation laws of California, provided,
however, that no temporary disability compensation shall be paid and medical
expenses shall be limited to reimbursement for expenditures otherwise
qualified for reimbursement which are not covered by the volunteer's health
plan, other available insurance coverage, or other third party (i.e. ,
Federal, State or other payment) .
2 . Public Liability. The County through its self-insurance program
shall defend and indemnify volunteers upon request against liability claims
initiated by third parties arising out of acts or omissions occurring within
the scope of authorized volunteer services, unless the volunteer acted or
failed to act because of actual malice, fraud, corruption or gross
negligence. Volunteers using personal automobiles in performing authorized
services must maintain liability insurance at limits which as a minimum
comply with the California Financial Responsibility law and must have a valid
driver's license. the protection afforded by the County shall be in excess
only of any other valid and collectible public liability or automobile
liability insurance maintained by or which provides coverage for the
volunteer. Volunteers may be permitted to operate County vehicles in the
performance of authorized volunteer services.
3 . Expense Reimbursement. Volunteers shall be reimbursed for actual
and necessary expenses in performance of authorized volunteer services at the
same rates and in accordance with regulations and procedures established for
County employees, except that a flat mileage rate of $0.15 per mile for use
of personal vehicles will be allowed. No reimbursement will be made for any
child care expenses, mileage from the personal residence of the volunteer to
the County facility or service location or for damage to personal vehicles of
volunteers used when performing authorized volunteer services.
2
CONTRA COSTA COUNTY
POLICY STATEMENT ON VOLUNTEER PROGRAMS
The use of volunteers in performing specific services is a valuable resource and
provides an avenue for citizen participation in various County programs which is
recognized as being of public benefit. In recognition of the benefits which may
be derived from volunteer services, it is hereby declared that it shall be County
policy to encourage and promote volunteer programs determined to be in the public
interest.
It is County policy that volunteers will not replace County employees but will
provide services to supplement or enrich regular County programs and services.
This policy statement is designed to provide the framework for all County
volunteer programs and activities. The following guidelines are adopted for
volunteer programs:
VOLUNTEER PROGRAMS
A complete description of each volunteer program shall be submitted by the
department head to the County Administrator for review and presentation to the
Board of Supervisors with his recommendation.
Factors to be considered in evaluating programs are the need for and public
benefit to be derived from the volunteer program, associated County cost and
staff effort required for such a program, the potential for injury to volunteers,
and the possibility for injury to others including injuries giving rise to
possible liability claims.
Regulations and procedures including, but not limited to, such matters as
eligibility, training, supervision and roster control, may be promulgated by the
County Administrator for guidance of departments to assure proper administration
and control of volunteer services.
VOLUNTEERS
A volunteer is defined as a person who renders services gratuitously and has been
accepted in the volunteer program. The volunteer is not an employee of the
County.
In recognition of the benefit to the County derived from volunteer services,
authorized volunteers serving in programs approved by the Board of Supervisors
shall be provided the benefits indicated below.
1
CONTRA COSTA COUNTY
POLICY STATEMENT ON VOLUNTEER PROGRAMS
1. Injury to Volunteer. Authorized volunteers are not under the purview
of the workers' compensation laws of California. In lieu thereof and in return
for the volunteers waiver of any claim against the County for illness, injury or
other harm arising from acts or occurrences while providing volunteer services,
the County shall provide, in the case of authorized volunteer services, through
self-insurance, for reimbursement of medical expenses and minimum permanent
disability compensation equal to that afforded under the workers' compensation
laws of California, provided, however, that no temporary disability compensation
shall be paid and medical expenses shall be limited to reimbursement for
expenditures otherwise qualified for reimbursement which are not covered by the
volunteer's health plan, other available insurance coverage, or other third party
(i.e. , Federal, State or other payment) .
2. Public Liability. The County through its self-insurance program
shall defend and indemnify volunteers upon request against liability claims
initiated by third parties arising out of acts or omissions occurring within the
scope of authorized volunteer services, unless the volunteer acted or failed to
act because of actual malice, fraud, corruption or gross negligence. Volunteers
using personal automobiles in performing authorized services must maintain
liability insurance at limits which as a minimum comply with the California
Financial Responsibility law and must have a valid driver's license. The
protection afforded by the County shall be _in excess only of any other valid and
collectible public liability or automobile liability insurance maintained by or
which provides coverage for the volunteer. Volunteers may be permitted to
operate County vehicles in the performance of authorized volunteer services.
3. Expense Reimbursement. Volunteers shall be reimbursed for actual and
necessary expenses in performance of authorized volunteer services at the same
rates and in accordance with regulations and procedures established for County
employees, except that a flat mileage rate of $0.15 per mile for use of personal
vehicles will be allowed. No reimbursement will be made for any child care
expenses, mileage from the personal residence of the volunteer to the County
facility or service location or for damage to personal vehicles of volunteers
used when performing authorized volunteer services.
2
Administrative Bulletin Contra Number 321
Costa Replaces
' OffiZn of the County Administrator Date l 7 -26-78
County Section
SUBJECT: Rules and Procedures to be Followed
by County Departments for Authorized
Volunteer Programs
I.. GENERAL
This bulletin provides the rules and procedures to be
followed by County departments governing entrance, training, and
supervising of volunteers under County authorized volunteer
programs , including the policies and procedures for reimbursement
of expenses ; medical and permanent disability benefits ; and legal
defense and indemnification against liability claims initiated by
third parties . These regulations and procedures are promulgated
in accordance with the policy adopted by the Board of Supervisors .
II . RULES AND PROCEDURES
County departments shall submit to the Office of the County
Administrator a description of each volunteer program, the number
of volunteers to be assigned, County staff requirements for
coordination and County expenditures and funding involved. Such
volunteer program definition, following review by the Office of
the County Administrator, shall be forwarded to the Board of
Supervisors for approval.
After Board approval, rules and procedures , as follows , shall
be adopted, and copies forwarded to the County Administrator:
A. County departments sponsoring volunteer
programs shall have a staff member assigned
as a volunteer coordinator, who will be respon-
sibile for the selection and acceptance of
volunteers . Personnel matters regarding the
volunteers will be referred to the volunteer
coordinator. Volunteers will work directly
with other staff members and will be under
their supervision for each assignment . Each
County department will forward to the County
Administrator the name and telephone number
of the employee (s) assigned as the volunteer
coordinator. Volunteers will be provided
with initial orientation and training by the
2 .
volunteer coordinator . Where appropriate,
confidentiality requirements shall be
explained, reading materials assigned and
discussion groups held on a regular basis with
the volunteers.
B. The volunteer coordinator will also be respon-
sible for requiring volunteers to fill out,
read and sign the application form, and if
such volunteer is accepted, the volunteer
coordinator will fill out the registration
form (just below the application form) showing
acceptance of the volunteer, date services
commence and terminate , any remarks ^he may
wish to include with respect to the capability
of the volunteer and limitations as to tasks
to be performed, and lastly the service
authorized to be performed by the volunteer .
If the volunteer is a minor, the parental
consent form shall be completed and signed by
the parent or legal guardian. Forms to be
used by departments are attached. Departments
may continue to use forms developed for
volunteer programs which include information
needed by the department in addition to that
indicated on the attachments . Any obvious or
suspected disabilities of a volunteer shall
be discussed with the County Safety Officer.
If reimbursement of actual and necessary
expenses in performing volunteer services is
contemplated, volunteer must sign Oath of
Allegiance form in accordance with established
department procedures when registering to
perform authorized volunteer services with the
County.
The volunteer coordinator shall be responsible for mainte-
nance of a log listing pertinent information with respect to all
authorized volunteers, including date services commenced and
terminated. Records are to be retained at least five years from
the date of the last volunteer service for subsequent reference
on claims which may be presented by either the volunteer or any
third party allegedly injured.
3.
If a volunteer is to use his personal vehicle in the course
of authorized volunteer services, he will be required to fill out
the "Volunteer Auto Insurance Declaration" form. Volunteers must
check with their insurance agent or broker to make certain that
liability insurance is extended under their policy while their
vehicle is being used for volunteer activities . Auto insurance is
required for all volunteers who will use their personal, automobile
while performing authorized volunteer services with at least the
following limits :
$15 , 000 for injury to or death to one person
$30, 000 for injury to or death to two or more
persons in one accident
$5 , 000 for property damage
The volunteer must furnish a valid California motor vehicle
operators license if he is to use a vehicle and the license number
together with insurance policy number duly noted on the Auto Insur-
ance Declaration (form attached) . A Certificate of Insurance or
other evidence of insurance may be requested and placed on file .
III. PROCEDURE IN CASE OF ACCIDENT OR INJURY
When a volunteer is injured while performing authorized
volunteer services , the supervisor shall arrange for medical care
as necessary and appropriate in accordance with normal departmental
operating procedures . The volunteer' s supervisor shall immediately
thereafter complete the Supervisor' s Report of Occupational Injuries
or Illness (Form AK-30) . The supervisor shall then forward the form
to the volunteer cordinator who within 24 hours shall submit the
report through department channels to the Safety Division of the
Civil Service Office . The form shall indicate that the injured
party is a volunteer. A copy of the report must be .forwarded to
the Office of the County Administrator.
All medical bills received by the volunteer not otherwise
covered by health insurance, other insurance, or third party pay-
ment shall be forwarded to the Office of the County Administrator.
Such bills must be itemized and indicate the date of injury.
County payments will be made jointly to the volunteer and to the
medical provider.
Any claims for permanent disability compensation shall be
referred to the Office of the County Administrator for review and
adjustment . Prior to final settlement and payment of any such
claim, the volunteer shall execute an appropriate form releasing
the County from any further liability and agreeing that such
compensation shall be the sole and exclusive remedy with respect
to the injury sustained.
1
4
When there is an accident resulting in third party personal
injury or property damage, the appropriate accident report form
Shall be completed by the supervisor and forwarded to the volunteer
coordinator. The subsequent procedure to be followed shall be`
identical to that applicable as in accidents involving County
employees .
IV. LIABILITY
.The County under its self-insurance program upon request shall
defend and indemnify the volunteer against liability claims initi-
ated by third parties arising from acts or omissions occuring
within the . scope of authorized services , unless the volunteer acted
or failed to act because of actual fraud, corruption, malice or
gross Negligence ,
However, the County shall provide automotive liability insur-
ance protection as excess only of the limits under the volunteer' s
personal automotive liability policy. Such County insurance
protection does not cover any damages to the vehicle or, t e volun-
teer, including any cieductibie provision which must be Daid.
Maintenance of such records as determined necessary to assure
that adequate insurance protection is afforded shall be a respon-
sibility of the department ' s volunteer coordinator.
V. REIMBURSEMENT OF EXPENSES
Volunteers are eligible to receive reimbursement from the
County for certain actual and necessary expenses incurred in the
performance of authorized volunteer services . In order to claim
expenses , the volunteer must have signed the Oath of Allegiance
before any County officer authorized to administer oaths and meet
previously described insurance requirements .
Volunteers are governed by general County reimbursement
policies established for County employees with the exception of
mileage which will be reimbursed at a flat rate of $0. 15 per mile .
The County will not reimburse volunteers for child care ex enses ,
mileage rom t e vo unteer s residence to the County des gnated
f—ac-ility or service location or dama a to the vo unteer s personal
vehicle , inc u n any deEi_ctible provisions which are paid by t o
volunteer. : The volunteer must prow a inrormation to the volunteer
coordinator with respect to the automobile liability insurance
coverage maintained prior to use of the personal vehicle for
volunteer services and reimbursement of mileage claims . ,
5.
Volunteers are recognized as a valuable resource in perform-
ing services which are not provided by the County. The Board of
Supervisors has expressed its strong support of volunteer
programs . These policies and procedures have been developed for
the information and guidance of County staff and volunteers .
Acting County Administrator
CONTRA COSTA COUNTY
VOLUNTEER APPLICATION AND REGISTRATION FORM
Name Age Social Security No.
Home Address Home Phone
Business Address Business Phone
Driver ' s License No. , If Any
Service Preference
Acceptable Location
Do you have a health problem we should be aware of in an emergency?
Yes No (Describe - such as a history of back trouble ,
heart, epilepsy, diabetes , fainting , etc . )
Is there a medication you must take? Yes No
Is there a medication to which you are allergic? Yes No
If yes, medication is :
Medical, Hospital or Other Insurance
Person to Call in Emergency Address Phone No .
Interviewed by I have been informed against and accept
responsibility for any breach on my part
respecting confidential information . I
have read the Resolution adopted by the
Contra Costa County Board of Supervisors
Signature on volunteer programs . In return For the
benefits provided by Contra Costa County
Date in case of my illness, injury, death, or
third party liability while providing, or
resulting from acts or occurrences within
the scope of my authorized volunteer
services, and for my right to authorized
expense reimbursement, I waive any claim
on my behalf and on behalf of my heirs,
representatives, and assigns against the
County of Contra Costa or any of its
agents, servants or employees for illness ,
injury, debts or other harm arising from
my volunteer services, • whether or not
authorized .
Signature
1
CONTRA COSTA COUNTY
VOLUNTEER SERVICES
AUTO INSURAPICE DECLARATION
�. Date
This is to certify that I, the undersigned, am in possession
of a valid California Driver' s License ,
(Number)
My car
Expiration Date (Make)
(Model) ear License No .
is insured with ,
(Company)
Po icy No . ) Expiration Date)
I further certify that I have minimum liability insurance coverage
as follows : $15 , 000 for injury to, or death of, one person ;
$30 , 000 for injury to, or death of, two or more persons in one
accident; $5 , 000 for property damage .
Signature
a '
CONTRA COSTA COUNTY
PARENTAL CONSENT FORM
VOLUNTEER PROGRAIX
Name of Minor:
Address :
Birthdate:
Volunteer Activity :
The above person, a minor, desires to perform volunteer services
for the County in accordance with the attached application form.
As parent/guardian of this minor, permission is hereby granted
for him/her to participate in the volunteer program. My child does
not have any physical or medical problems which would prohibit or
limit participation in the volunteer program, except:
In case of illness or emergency, please call:
Telephone Number:
I have reviewed the volunteer application and registration form and
give my consent for to participate in the volunteer
program subject to the terms and conditions expressed therein.
Signed by Parent/Guardian:
Date: