MMHA 6452 Week 8 Volunteer Screening Protocol Example

Screening by Access: A Tiered Volunteer Screening Protocol for Westfall Community Health Center

Student Name

Walden University

MMHA 6452: Board Governance and Volunteer Management

Instructor Name

Month Day, Year

Screening by Access: A Tiered Volunteer Screening Protocol for Westfall Community Health Center

Purpose and Principle

This protocol sets the screening each volunteer at Westfall Community Health Center completes before beginning work. It is organized by access: the more a role allows a person to reach patients, patient information or restricted areas without staff present, the more the center verifies before the role begins. Screening everyone at the highest level would discourage volunteers for low-risk roles and collect personal information the center has no need to hold. Screening everyone at the lowest level would leave patients exposed in the roles where risk is greatest. The protocol carries out section 3.3 of the board's Volunteer Engagement policy, which requires screening matched to each role's access before work begins.

Access Map

Table 1 groups volunteer roles by what a person holding them can reach.

Table 1

Access Map for Volunteer Roles

Tier 1: Public Events Alongside Staff

Trigger: a Level 1 role. Verified: identity, by viewing a government-issued photo ID; a signed volunteer agreement acknowledging the role's limits. Told first: the candidate is told what will be checked and that no background check is required for this role. Level 1 volunteers who later move to another role complete the higher tier first.

Tier 2: Public Areas During Clinic Hours

Trigger: a Level 2 role. Verified: identity; two references from people who are not relatives, contacted by the coordinator; a search of the federal List of Excluded Individuals/Entities, which identifies people barred from federal health care programs (Office of Inspector General, 2024); a criminal background check through a consumer reporting agency covering the past seven years; and completion of privacy training, since Level 2 volunteers will see some patient information and are part of the center's workforce under privacy rules (45 C.F.R. § 164.530).

Told first: before any information is collected, the candidate receives a written description of every check, who will see the results and how long they will be kept. For the criminal background check, the candidate receives a stand-alone written disclosure that a report may be obtained and signs a separate authorization, the steps federal law requires before a consumer report is obtained for employment purposes (15 U.S.C. § 1681b). The center follows these steps for volunteers whether or not counsel concludes the law strictly requires them, because they cost little and protect candidates.

Tier 3: Unaccompanied Patient Contact

Trigger: a Level 3 role. Under section 5.2 of the board policy, no Level 3 role exists until the board approves it. Verified, if approved: everything in Tier 2, plus a check of the national sex offender public registry, a criminal background check covering every state of residence in the past ten years, and any health screening the Chief Medical Officer requires for work in clinical areas. Told first: as in Tier 2, with the additional checks described in writing before consent.

Reviewing Results

The volunteer program coordinator receives all results. A record on the exclusion list disqualifies the candidate for any role that involves federal program activity, which at a health center is nearly every role, and the coordinator informs the candidate. A criminal record does not disqualify automatically. The coordinator refers any record to the Human Resources Director, who considers the nature of the offense, how long ago it occurred and its relevance to the specific role, using the same criteria the center applies to employees. Before deciding against a candidate based on a background report, the center sends the candidate the background report itself along with the federal statement of consumer rights, and allows at least five business days for the candidate to explain or dispute it (15 U.S.C. § 1681b). The Human Resources Director decides, and the decision is recorded with its reasons.

Record Handling

Screening results are kept in a locked electronic folder separate from volunteer schedules and training records. Only the coordinator, the Human Resources Director and the Compliance Officer may open it. Site supervisors are told only that a volunteer has cleared the required tier, never the details. Results are kept for the duration of the volunteer's service plus three years, then destroyed. Volunteers may request copies of their own records. Screening information is never used for any purpose other than the volunteer's placement.

Matters Deferred to Counsel

Several external requirements may affect this protocol, and the center's counsel should resolve them before it is adopted: state laws that limit when criminal history may be considered or that require specific notices; state requirements for screening people who work with minors or vulnerable adults, which may apply if the center later places volunteers in its pediatric or behavioral health areas; whether the federal consumer reporting rules for employment purposes apply to volunteers; and any requirement of the center's insurer. The protocol has been written to follow the stricter reading where the answer is uncertain. It will be reviewed with the board policy after the program's first year.

Rescreening and Changes in Role

Tier 2 and Tier 3 volunteers are rescreened every three years, and the exclusion list search is repeated every year, matching the center's practice for employees. A volunteer moving to a role at a higher access level completes the higher tier before starting the new role, even if the earlier screening is recent. Volunteers are asked at each six-month review whether anything has changed that the center should know about, and the volunteer agreement asks them to report any new criminal charge promptly. A volunteer who stops serving for more than twelve months is screened again on return. These steps keep the screening record current without repeating every check each year, which would add cost and discourage people who have already served well.

References

Administrative requirements, 45 C.F.R. § 164.530 (2024).

Office of Inspector General. (2024). List of Excluded Individuals/Entities (LEIE) [Data set]. U.S. Department of Health and Human Services.

Permissible purposes of consumer reports, 15 U.S.C. § 1681b (2023).