Covid-19 Vaccinations: Volunteer Agreement Form

Stewards are an important and valued part of C-19 vaccination programme and we are very grateful for your decision to volunteer with us for a minimum of two stewardship shifts (ideally in accordance with your second vaccine administration). We are committed to ensuring that your volunteer experience is both rewarding and enjoyable.

Please read our Volunteer Agreement to Steward during the COVID-19 Vaccination Programme Information page and then complete the following form.

This Volunteer Agreement is binding in honour and in trust. No legally binding contract of employment or otherwise can be imposed on volunteers.

We are truly grateful for your help and support!

Covid-19 Vaccinations: Volunteer Agreement Form

Covid-19 Vaccinations: Volunteer Agreement Form

Volunteer Details

Title:
Gender:
Please include the postcode
Please state the number of the role you would prefer. You can find out the role number within the Station column of the C19-Vaccine Programming – Role and Station Profile Document.
Which shift would you prefer?

Emergency Contact Details

SPPCN Confidentiality Agreement

This agreement aims to ensure that any Volunteer stewarding for Salisbury Plain PCN during the C-19 vaccination programme is aware of their duties and responsibilities with regard to confidentiality, as set out below.

We reserve the right to refuse access to any Volunteer, in the PCN’s opinion, there is any doubt about that person’s commitment to abide by this confidentiality agreement.

  • All visitors must report to reception on arrival.
  • Confidentiality is the duty of a person to not disclose anything learned from a patient who has attended, consulted or been treated, without that person’s consent.
  • Confidentiality is the cornerstone of health care and central to the work of everyone working in general practice.
  • All information about patients is confidential: from the most sensitive diagnosis, to the fact of having visited the premises or being registered with one of the constituent Practices of the PCN.
  • The duty of confidentiality owed to a person under 16 is as great as the duty owed to any other person.
  • All patients can expect that their personal information will not be disclosed without their permission (except in the most exceptional circumstances when disclosure is required when somebody is at grave risk of serious harm).
  • Any information, no matter how irrelevant or trivial it appears, which is  seen or overhead whilst volunteering with us must not be discussed with or disclosed to anyone else (including PCN or constituent Practice staff and/or attached staff) under any circumstances.

Breach of confidentiality will be considered sufficient grounds for termination of the Volunteer Agreement and will be investigated and reported to the Information Commissioners Office (ICO) via our Data Security and Protection Toolkit.  

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