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Summary of Utilization of Volunteer Practitioners during Emergency Operations (For Non Critical Access Hospitals), COVID-19

This summary refers to volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license, certification, or registration.

The use of volunteer practitioners who are not licensed independent practitioners may only be implemented when emergency operations plans have been activated. Refer to Standard EM.02.02.15 for additional information.

Hospitals will provide in writing:

  • Who is responsible for assigning responsibilities to the volunteer practitioners
  • What methods will be used for overseeing the volunteer practitioners
  • How to distinguish volunteer practitioners from regular staff

Volunteer Practitioners are to obtain valid government-issued photo identification and ONE of the following:

  • A current picture identification card from a health care organization that clearly identifies professional designation
  • A current license, certification, or registration
  • Primary source verification of licensure, certification, or registration
  • Identification indicating that the individual is a member of a:
    • Disaster Medical Assistance Team (DMAT)
    • Medical Reserve Corps (MRC),
    • Emergency System for Advance Registration of Volunteer Health Professional
    • Other recognized state or federal response organization or group
  • Identification verifying the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances
  • Confirmation by hospital staff with personal knowledge of the volunteer practitioner’s ability to act as a qualified practitioner during a disaster

Hospitals will oversee the performance of each volunteer practitioner and determine within 72 hours if assigned duties should continue

Verification of licensure occurs within 72 hours or as soon as the disaster in under control. If not completed due to extraordinary circumstances the following must be documented:

  • Reason(s) verification could not be completed
  • Practitioner demonstrated ability to continue providing care
  • Hospitals attempts to complete verification process

If, due to extraordinary circumstances, primary source verification of licensure of the volunteer practitioner cannot be completed within 72 hours of the practitioner’s arrival, it is performed as soon as possible.


Topics: Emergency Preparedness

Revision Date: 4/2/2020

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