Peer Mentor Policy and Procedure Handbook - …Peer mentor policy and procedure handbook. Target...
Transcript of Peer Mentor Policy and Procedure Handbook - …Peer mentor policy and procedure handbook. Target...
PeerMentorHandbook 1
PeerMentorPolicyandProcedureHandbook
PeerMentorHandbook 1
Index–PeerMentorPolicyandProcedureHandbook
Section Page
1.WelcometoPeerSupport5• OverviewofHandbook• About[AGENCY]
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2.PeerMentorExpectations7• Professionalism• CreatingSafety• DevelopingRelationships• SupervisionandSupport• GeneralDutiesandResponsibilities• One-to-OnePeerSupportDutiesandResponsibilities• GroupPeerSupportDutiesandResponsibilities• TipsforFacilitating• ViolationofProgramPolicy• Honorariums• LeaveofAbsence
7899
10101112131414
3.PrivacyandConfidentiality15• Guidelines• Purpose• Policy• BreachofConfidentiality• OathofConfidentiality
1515151617
4.Ethics18• CodeofEthics 18
5.CodeofConduct21• RespectfulWorkplacePolicy–BullyingandHarassment• ReportingaComplaint
o Procedureso Informalo Formal
• CodeofConduct/ConflictofInterestDeclaration
212324252628
6.Forms29• Story/PhotoConsentForm• IncidentReport• ProgressNotes• PeerMentorVolunteerRecordSheet
29303233
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PeerSupportToolkitforPeoplelivingwithHIVand/orHepatitisCToolkitPurposeandObjectives:Thistoolkitprovidespracticalguidanceandtoolstoassistcommunity-basedorganizationsorgroupstodeliversocialandemotionalpeersupportservicestopeoplelivingwithHIVand/orhepatitisC(HepC).Itincludesfourparts.
1. Gettingstarted:aguidetodevelopanddeliverpeersupportservices.2. Trainingpeermentors:facilitationguide.3. Becomingapeermentor:participanttrainingguide.4. Peermentorpolicyandprocedurehandbook.
TargetPopulation:ThistoolkitisintendedtosupportthedevelopmentorenhancementofsocialandemotionalpeersupportservicesforpeoplelivingwithHIVand/orHepCintheInteriorHealthRegionofBC.TheInteriorRegionincludesEastKootenay,KootenayBoundary,OkanaganandThompsonCaribooShuswap.
ImagebyAarynSecker.OriginallycreatedforBreastfeedingArtExpoArtCatalogue,2017,InteriorHealth&KCR–CommunityResources.
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HowtheToolkitWasDeveloped:CMHAKelownaengagedtwoadvisorygroups(contentexpertsandcontextexperts)toprovideguidanceandexpertisetothedevelopmentofthetoolkit.CMHAKelownareviewedpeersupportmaterialsfromawidevarietyofsourcesandidentifiedkeyguidingdocuments.TheadvisorygroupsmetacombinedtotalofninetimesoverthecourseofsixmonthsshapingthecontentandlayoutofthetoolkittoensureitisrelevanttopeoplelivingwithHIVand/orHepCintheinteriorregionofBritishColumbia.Acknowledgements:a. AdvisoryGroups:Oneadvisorygroupinvolvedtheparticipationof8individualswith
livedexperienceofHIVand/orhepatitisCandonehealthoutreachnurse,mostofwhoweremembersofthePeerAdvisoryCommitteeforSTOPHIVatthetime.
Theotheradvisorygroupinvolvedtheparticipationof16individualsfromthefollowing10organizations:
i. ANKORS:AIDSNetworkKootneysOutreachandSupportSociety.ii. ASKWellness:AIDSSocietyofKamloops&MerrittBranch.iii. CanadianMentalHealthAssociationKelowna&DistrictBranch.iv. InteriorHealthAuthority,HIVandHealthOutreachProgram,Population
Health.v. LivingPositiveResourceCentreKelowna.vi. NorthOkanaganYouth&FamilyServicesSociety.vii. PacificHepatitisCNetwork.viii. Penticton&DistrictCommunityResourceSociety.ix. PositiveLivingBC.x. REL8Okanagan.
b. Funder:Thisprojectwouldnothavebeenpossiblewithoutfundingandleadership
providedbytheInteriorHealthAuthority,HIVandHealthOutreachProgram,PopulationHealth.
c. Authors:AlisonKyte,JaymePereiraandtheCanadianMentalHealthAssociationKelowna&DistrictBranch.
d. Formatting:AarynSeckerandtheCanadianMentalHealthAssociationKelowna&DistrictBranch.
References:ThecontentinthishandbookwasadaptedfromnumerousunpublisheddocumentscreatedbytheCanadianMentalHealthAssociation(CMHA)Kelowna.TheyincludetheCMHAKelownapersonnelmanual,CMHAKelownavolunteerpolicyandprocedurehandbookandCMHAKelownapoliciesforpeersupportprogram.
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Disclaimer:TheContentofthisToolkitisintendedforeducationalandinformationalpurposesonly.TheContentisnotintendedtoprovidemedicaladviceand,totheextentthatmedicaladviceisrequired,usersshouldconsultwithqualifiedmedicalprofessionals.InteriorHealth,CMHAKelowna,thecontributorsandauthorsofthisToolkitshallhavenoliability,whetherdirect,indirect,consequential,contingent,specialorincidental,relatedtoorarisingfromtheContentoftheToolkitortheusethereof.Copyright:©InteriorHealthAuthority,BC,Canada,2018.Allrightsreserved.Nopartofthis Toolkit may be used, reproduced, stored in a retrieval system, modified or madeavailableonanetwork,usedtomakederivativeworks,ortransmittedinanyformorbyanymeans,electronic,mechanical,photocopying,recording,orotherwise,withoutpriorwrittenpermissionfromInteriorHealth.
ReproductionofthisToolkit:PermissiontoduplicateoradaptthistoolkitmustbesoughtthroughInteriorHealthAuthority,HIVandHealthOutreachProgram,PopulationHealth.ContactIhhealthoutreach@interiorhealth.ca.EditableTemplates:Formandcertificatetemplatesineditableworddocumentsareavailablebyrequest.PleaseemailIhhealthoutreach@interiorhealth.caattheInteriorHealthAuthority,HIVandHealthOutreachProgram,PopulationHealth.EditableHandbook:Part4,thepeermentorpolicyandprocedurehandbookisavailablebyrequestasaneditableworddocument.PleaseemailIhhealthoutreach@interiorhealth.caattheInteriorHealthAuthority,HIVandHealthOutreachProgram,PopulationHealth.HowtoCitethisDocument:Kyte,A.,Pereira,J.(2018).PeersupporttoolkitforpeoplelivingwithHIVand/orHepatitisC:part4Peermentorpolicyandprocedurehandbook.Kelowna,BritishColumbia:CanadianMentalHealthAssociationKelowna&DistrictBranch.ContactInformation:CMHAKelowna:websitecmhakelowna.org,[email protected],phone250-861-3644.InteriorHealthAuthority:[email protected]. Thecompletetoolkitcanbefoundatwww.interiorhealth.ca/PeerToolkit.
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Welcome!Congratulationsandwelcometo[AGENCY]!Wewouldliketothankyouinadvancefortakingtheinitiativetogetinvolved.Wehopeyourpeermentorexperiencewillberewardingandenjoyable.Pleasereadthispeermentormanualcarefully–itcontainsinformationabout:
• [AGENCY]• Peermentorroleandexpectations• Privacyandconfidentialityagreement• Codeofethics• Respectfulworkplacepolicy• Codeofconduct/conflictofinterestdeclaration• Photoconsentform• Peermentortimesheet
Pleasesignandsubmittherelevantformsandreadallthedocumentationprovided.Thepeersupportprogramstaffwillprovidefurtherorientationtoyourrole.Oneormoreprogramstaffwillprovideyouwithdirectsupervisionintheroleofpeermentor.TipsonhowtomakethemostofyourpeermentorroleBehonest:Makesuretheprogramstaffisawareofyourprevioustraining,yourabilityincertainareas,andifyouneedmoretrainingonhowtodoataskyouhavebeenaskedtocomplete.Wewantyoutobecompletelycomfortableinyourabilitiestoperformataskandbeabletoaskforassistanceifneeded.Beprompt:Returncallsande-mailsinatimelymanner.Besuretoshowupontimeforyourscheduledshiftsandmeetings.Showingupontime(orearly)demonstratesthatyoucareaboutyourworkandareengagedintheprocess.Enjoyyourwork:Ifyoufeelthatyouneedmoreofachallengeorthatyouaren'tlearninganynewskillsinyourrole,speaktotheprogramstaff.Findoutifthereareanyothertasksorprojectsyoucouldhelpoutwiththatwouldbeabetterfit.Ifitistimeforyoutomoveontootheropportunities,notifytheprogramstaff.
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About[AGENCY][Example:TheCanadianMentalHealthAssociationisoneoftheoldestnationalcharitableorganizationsinCanadaandtheoldestnationalmentalhealthcharity.Eachyear,CMHAdivisionsandbranchesacrossCanadaprovideservicetomorethan100,000Canadiansthroughthecombinedeffortsofmorethan10,000volunteersandstaffinlocallyrunorganizationsinmorethan135communities.CMHAhasbeeninKelownasince1956.Ourorganizationhasbeenattheleadingedgeofprovidinginnovativeservicesandsupportstoassistpeoplewithmentalillnesstodevelopthepersonaltoolstoleadmeaningfulandproductivelives.Webelieveinarecoveryvisionofservicewiththeideathatpeoplecanrecoverfrommentalillnesswhentheyplayanactiveandempoweredroleintheirjourney.Ourorganizationlooksatthewholepersonratherthansimplytheirillness.Wetaketheapproachthatallcitizensinourcommunityhavetherighttoaroofovertheirhead;anopportunitytoearnadecentincome,accessmeaningfulsocial,work,educationalandrecreationalactivitiesandtreatmentthatsupportstheirrecovery.Weareoneoftheonlyorganizationsthatalsofocusonmentalhealthpromotion,thatisprovidingeducation,skills,advocacyandcommunity-basedresearchthatempowersindividualsandfamiliestoimproveandenhancetheirmentalhealthandwellbeing.]
[AGENCY]MISSION[Example:Asthenation-wideleaderandchampionformentalhealth, CMHAfacilitatesaccesstotheresourcespeoplerequiretomaintainandimprovementalhealthandcommunity integration,buildresilience,andsupportrecoveryfrommentalillness.][AGENCY]VISION[Example:Mentallyhealthypeopleinahealthysociety:Weseektoeducatepeopleaboutmentalhealthissuesandchangethewaysthecommunityviewsandtreatspeoplewithmentalillness.Webelievethatallpeoplewithmentalillnessshouldhaveaccesstoappropriateandadequatesupport.Webelieveindevelopingandmaintainingpartnershipsinthecommunity.]
YOURLOGOHERE
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PeerMentorExpectations
Professionalism
• Youarerepresentingthe[AGENCY]anditisexpectedthatallvolunteersbeappropriateinattitude,mannersandappearance.Youareinaprofessionalenvironmentandareexpectedtotreatotherswithdignityandrespect,performassignedtasksandrequestassistanceifrequired.Consultthe“RespectfulWorkplace”documentformoreinformation.
• Dressneatlyandforcomfort.Casual-professionalisthelooktomodelwhilepeermentoringat[AGENCY].
• Understandyourroleanditslimitations.Consultstaffifunsure.Forexample,ifyou
haveanyconcernsaboutapeer,checkwith[AGENCY]staffmembers.Donotcontactthepeer’scasemanageroranycommunitypartneroragencyinvolvedwiththepeer.
• Volunteersarenotabletomakestatementsonbehalfof[AGENCY]tothemediaunlesstheexecutivedirector(ordesignate)hasgrantedpermission.
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CreatingSafetyinaProfessionalManner
• “Friendship”-Friendshipimpliesamutualrelationshipandbecausethepeermentorisinahelpingroleonbehalfoftheagency,developingpersonalrelationshipswithpeersisnotadvised.Thefocusofmentoringisonthepeer’sneeds.Ifyouhaveapersonalconnectionwithapeerasaresultofothersettings,ensuretheprogramstaffisawareanddiscusshowthismayimpactyourabilitytopeermentor.
• SharingPersonalInformation-Ensurethatyourpersonalcontactinformation,includinghomeaddress,socialmediainformationandifpossiblepersonalphonenumbersandemailaddressesbekeptconfidential.Notrespectingthisboundarycancreatevulnerabilityandexpectationsbeyondthepeermentor/peerrelationship.
• Respect-Alllifestyles,identities,preferences,cultures,religionsandspiritualbeliefs
aretoberespected.Apeermentormaychoosetonotdiscusscertaintopics.
• GivingAdvice-Apeermentormayactasaresourcetopeerssuchasprovidinginformationaboutcommunityprograms.Atnotimeisgivingadviceappropriate(e.g.“IfIwasyou….”,“Ithinkyoushould…”).
• Financial-Donotborrow,lendorholdanymoneyorpersonalitemsfrompeers,includingcigarettes.
• PhysicalContact-Physicalcontactisdiscouragedbecauseitcanbeeasilymisinterpreted,consideredfavouritismorviolatesapeer’sboundaries.
• Gifts-Giftsaregenerallynotaccepted.Acceptinggiftscangivetheimpressionthatthe
receiverisbeinginfluencedtoshowfavourordisfavourtosomeoneandmayowethepeersomethinginreturn.Respectfullydeclinetheofferandseekstaffassistanceintheeventthereisconcernthattheremaybeoffencetakenorifthegiftisnotexpensiveandcanbeshared(e.g.aboxofchocolates).AllgiftsreceivedareconsideredthepropertyofAGENCY.
• ConflictofInterest-Thisisasituationinwhichapersonisinapositiontoderive
personalbenefitfromactionsordecisionsmadeintheirofficialcapacity.Itisimperativethatapeermentor’spositionatAGENCYisnotusedtopromotepersonalgain.
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AdditionalSafetyExpectations
• Peermentorsarenotpermittedtotransportpeersduringorafterpeermentoringhours.
• Smokingbypeermentorsispermittedonlyinthedesignatedarea.• Defertostaffifthereareanysafetyconcerns,suchasdruguseorpossession,or
damagetotheproperty.Securethesituation,keepyourselfsafeandassistthepeersunderstaffdirection.Donotphysicallyinterveneintheeventofadangerousincident.
• Peermentorsareprohibitedfromusingalcoholordrugswhileperformingpeersupportduties.Ifprescriptionmedicationisaffectingtheabilityofeitheramentororpeertoperformtheirduties,anyvisitorgroupplannedneedstoberescheduledtoatimewhentheeffectswillnolongerbepresent.Visitsmaynottakeplacewhenapeerisundertheinfluenceofalcoholordrugs.
• Reportanycriminalchargestotheprogramstaffcontact.
DevelopingRelationshipsApeermentorisencouragedtodeveloprelationshipswithmanypeersasitrelatestotheworkthatisdone.• Listen.• Empathize.• Giveinformationwhenitisrequested.• Establishandmaintainhealthyboundarieswithpeers.• Empowerandsupportpeerstomaketheirowndecisions.• Bemindfulofwhenandhowself-disclosureisusedandkeepthefocusonthepeer’s
needs.• Redirectpeerstoappropriateresourcesiftheyrequiresupportthatisoutsidethe
peermentor’sscopeofpractice.
SupervisionandSupport• Newpeermentorswillhaveaninitialperformancereviewafterthreemonths.Regular
reviewswillthentakeplaceonceperyear.• Peermentorswillattendamandatorymonthlyteammeeting.Supportbywayof
coaching,guidance,problem-solvingandtrainingisofferedbyprogramstaffaswellaspeermentorsinagroupstructure.
• Peersupportprogramstaffareavailabletoprovideindividualsupervisionandsupportonanas-neededbasis.
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GeneralDutiesandResponsibilities• Peermentorsneedtoinformthepeersupportprogramstaffinadvanceifunableto
attendanypeermentoractivities(meetings,groups,workshops,training,etc.).• PeermentorsmustsubmitacompletedPeerMentorServicesVolunteerRecordSheet
attheendofeverymonth.• PeermentorsmustfileanIncidentReportfollowinganyconcerningissuesor
occurrencesorunusualcircumstancessuchassuicidalbehaviour,violence,sexualinappropriateness,healthcrisisand/orifemergencyserviceshavebeencontacted.Peermentorsmustnotifythepeersupportprogramstafforintheirabsence,anotheragencystaffmemberassoonaspossibleafteranincident.
• Notifypeersupportstaffimmediatelyofanysafetyconcernsthatmightarise.
One-to-OnePeerSupportDutiesandResponsibilities• Thisprogramprovidesone-to-one
support.Nooneelseistobeincludedinanypartofthemeetingswithapeer.
• Peermentorsmustnotrecruitpeerstobespecificallysupportedbythem.Peersmaybeself-referredorreferredbyahealthprofessional.Apeersupportprogramstaffwillmatchpeerswithmentors.Ifafteratrialperiod,thematchisnotworkingwell,thepeerormentormayasktobereassigned.
• Onceamatchismade,thereisamaximumof10visitsfor1-2hourspervisit.Itisunderstoodthattheremaybeoccasionswhenavisitisshorter.Ifapeerdoesnotshowupforavisit,itisthementor’sresponsibilitytoreportthistothepeersupportprogramstaffonthefollowingbusinessday.
• Thepeermentorinitiatesphonecontacttosetupweeklyorbi-weeklymeetingswiththepeeratamutuallyconvenienttimeandplace.
• Holdscheduledone-to-onevisitswithpeersinasafepublicenvironment.Maintainconfidentialityinpublicplaces.
• Thisisaformalrelationship.Peermentorsarefriendlywithpeers,butnotfriends.Therearenocasualmeetingsasfriendsorwithfriendsoutsidetheprogramandnoplannedactivitiesasfriends.
• Attheendoftheformalrelationship,afriendshipcancommenceifagreeduponbybothparties.
• Inthefirstmeeting,aftergettingtoknoweachother,mentorsaskpeersiftheyhaveanygoalstheywouldliketoset.Mentorsdonotsetthegoals.Mentorsrespectwherethepeerisatandempowerthemtomaketheirowndecisionsevenifitisnotwhattheywoulddo.
• Peermentorsareexpectedtonotebydate:o allcontactswithpersonsserved,
includingtelephonecontacts;o allmessagesleftand“noshows”;o othercollateralcommunication,
includingunusualoccurrences;o otherimportantincidents.
• Notesshouldberecordedonthedayofthevisit.
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GroupPeerSupportDutiesandResponsibilities• Groupsareco-facilitatedwithanotherpeermentor.• Peermentorsareexpectedtoarriveearlytosetupthespaceandwelcomeeachpeer
astheyarrive.• Atthestartofthegroup,remindeveryonethateverythingsaidintheroomis
confidentialandreviewthegroupguidelinesandprinciplesofsupporthandouts.• Makeanyannouncementsthatareneeded(programstaffwillprovideyouwiththese
aheadoftime).• Takeattendance.• Facilitatealargegroupdiscussiondrawinginspirationfromquotes,poetry,books,
video,etc.providedbyapeermentororaprogramparticipant.• Dependingonthenumberofpeerspresentatanygivenmeeting,thelargegroupmay
bedividedinto2or3smallergroupsforcheck-in.• Maintainapositiveandsupportiveenvironment.• Facilitateasmallgroupcheck-in,allowingeachpersontimetotalk.
o Everyoneneedsanequalopportunitytoshareandtoreceiveempathyfromothergroupmembers.
o Mentionhowmuchtimethereisintotalandforeachperson.Forexample,“Wehave45minutesand6people,sowehaveabout7minuteseach”.
o Modelrespectforeachother’stime.o Trytostartwithaperson(maybeyourself)whoyouknowwillrespectthetime
guidelinestosetthepaceforothers.Therewillbeoccasionswhensomeonewillneedalittlemoretime,soitcanbehelpfultohavethemsharetowardstheend,asnoteveryonewillneedalltheirallottedtime.
o Letpeopletalk.Forsome,thisistheonlyopportunitytoshareinasafe,confidentialenvironment.Althoughit’shelpfulforotherstosharesimilarexperiences,refocustheconversationifpeoplearegoingontoolongabouttheirexperiencesduringanotherperson’stimeoraregettingintoadvice-giving.
• Peermentorsareexpectedtokeeparecordbydateofattendance,generalgroup
content/topicsandunusualoccurrencesorincidents.Notesshouldberecordedonthedayoftheactivity.
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Tipstohelpyoufacilitategroups• Ifyouneedtorefocusthegrouporaperson,it’sbesttobestraightforwardand
honest.Someexamplesofwhattosay:o “I’mconcernedaboutourtime.Wehave10minutesleftand3morepeople
needtoshare”.o “Ithinkwe’vegottenabitofftrack.Whatwouldyousayistheonemainthing
youareworriedabout?”o “JustareminderthatthisisJoe’stime.I’dliketohearmoreaboutthatsubject
duringyourtime,Kyle.”o “Thisseemslikeanimportantthingforyoutotalkabout,I’mjustworriedwe
won’thaveenoughtimeforyoutogetthesupportyouneedingroup,wouldyouliketotalkwithastaffmember?”
• Itisveryimportanttointerveneifanothergroupmemberisbeingjudgmentalor
negative.Ifyoudon’t,peersmaythinkyouareinagreement.Someexamplesofwhattosay:
o “That’sfineifyoudon’tagreewiththatbehavior,butwearenotheretojudgeeachother”.
o “Ithinkweallknowwecanmakesomepoordecisionswhenundertheinfluenceofalcohol.”
o “That’sonewayoflookingatthat.Iseeitasanopportunityforgrowth.”• Atouragency,werespectthemedicalmodelandencouragepeopletoconsultwith
theirdoctorsandothermedicalprofessionals,especiallyinregardstomedication.o “It’sveryimportantyouspeaktoyourdoctororpharmacistbeforemakingany
medicationchanges.”o “Supplementscanbehelpful,butalsoharmfuliftakenwithcertain
medications.Pleasetalktoyourdoctorbeforetakinganythingbesidesyourprescription.”
• Useyourjudgmentinunusualcircumstances.
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ViolationofProgramPolicy• Peermentorswillbegiventhreewarningsconcerningviolationsofprogrampolicy.If
violationofpolicycontinues,thepeermentorwillbesubjecttodisciplinaryaction.Thismayincludeanenforcedleaveofabsence,re-trainingordismissal.
• Seriousviolationsofprogrampolicyincludingbreachofconfidentiality,harassment,bullying,engagementinunlawfulactivities,useofalcoholanddrugsandsexualmisconduct(sexualcomments,behaviours,innuendo,etc.)aregroundsforimmediatedismissal.
• Peermentorshavetherighttoappealanydisciplinaryaction.• AppealProcess:[Example:
o Thepeermentormuststateinwritingtheintentiontoappealandreasonsfortheappealandsubmittothepeersupportprogramstaff.Aresponsewillbeprovidedwithintwoweeks.
o Ifresolutionoftheappealisnotachievedatthislevel,thepeersupportprogramstaffwillarrangeforanagencymanagertoaddresstheappeal.Thiswilltakeplacewithintwoweeks.
o Ifresolutionoftheappealisnotachievedatthislevel,theagencymanagerwillarrangefortheexecutivedirectortoaddresstheappeal.Thiswilltakeplacewithintwoweeks.
o Thepeermentorwillbeabletoattendeachmeetingwithasupportpersonoftheirchoice.
o Thedecisionoftheexecutivedirectorwillbefinal.
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Honorariums• Overview:Anhonorariumisapaymentdesignedtorecognizeandacknowledgethe
contributionofmentorstothepeersupportprogramandtooffsetanypersonalcoststothepeermentorduringaservicesuchastransportationoractivities.Thispaymentshouldnotberecognizedasanequivalentvaluetoaprofessionalwage,butasatokenofappreciationandvalueassignedtoit.[Example:Honorariumswillbepaidforthefollowingpeersupportprogramactivities:one-to-onevisits,groupfacilitation,hospitalactivityfacilitation,socialgroupoutingfacilitationandpublicspeakingevents.]
• Payment:[Example:Honorariumpaymentswillbegivenintheformofachequeoncepermonthat$20.00perservice.Itistobenotedthatthehonorariumisgivenfortheserviceprovidedandnotbasedonthehoursofserviceprovided.]
• TaxableIncome:ItisimportanttonotethatCanadaRevenueAgencyregulationsstatethathonorariumsareconsideredassalaryandthusconstitutetaxableincome.Itisatthesolediscretionofthepeermentortodeclarehonorariumsreceivedasincomeontheirannualincometaxreturn.
• Processingthepayment:[Example:Inordertoprocessanhonorariumpayment,avolunteertimesheetmustbecompletedbytheendofthemonthandsignedbythepeersupportprogramstaffandsubmittedtotheagencyfinancialdepartment.Allinformationonthetimesheetmustbecompletedinorderforthepaymenttobeprocessed.]
LeaveofAbsence• Peermentorsareentitledtotakealeaveofabsencetopreventburnout,protect
healthandwellbeingorbecauseofrelapse.• Thepeermentoronleavedoesnotneedtoresignfromtheprogram.Thepeer
supportprogramstaffmustbeinformedoftheintentiontogoonleaveeitherverballyorinwritingandanapproximatereturndate,preferablynolongerthan3months.
• Apeermentormayberequiredtohaveaninterviewwithpeersupportprogramstaffbeforereturningtoactivementoring.Thementormayalsobeaskedtocompletearefreshercourse.
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PrivacyandConfidentialityAgreementforPeerMentors
ConfidentialityGuidelines
The[AGENCY]expectsthatpeermentorswhocomeincontactwithconfidentialinformationasaresultoftheirplacementat[AGENCY]will:a) Accessordiscussconfidentialinformationonlyasdirectedby[AGENCY]staff.Staffwilldeterminewhatis“needtoknowinformation”forpeermentorstocarryouttheirrole.
b) Preserveconfidentialityofconfidentialinformationwhileplacedat[AGENCY]andoutsideofwork.
c) Notengageinthereleaseorsharingofanyconfidentialinformation.Ifrequestedbyanotheragency(thisincludestheRCMP),deferto[AGENCY]staff.ThereareproceduresinplacefortheseprocessesinaccordancewiththeFreedomofInformationandProtectionofPrivacyAct.
d) Notshareprivateinformationaboutprogramparticipantsorco-workerswith(other)programparticipants.Informationaboutprogramparticipantsshouldnotbediscussedinpublicplaceswhereconversationsmaybeoverheard.Allinformationofachildprotectionnatureorsuicideideation(thoughtsexpressingintenttodie)mustbereportedtoprogramstaffimmediately.
e) Redirectanyprogramparticipantsrequestingaccesstotheirfiletoprogramstaff.PurposeToprotectthelegalrightsofourprogramparticipants,staffandstakeholderstoprivacyoftheirpersonalandbusinessinformationinourcustodyandcontrol.Peermentorswillbeprivilegedtoconfidentialinformationandthereforemustadheretotheconfidentialitypolicyandagreement.
PolicyInallcircumstances,peermentorswillremainawareoftherightsofprogramparticipantstohaveinformationaboutthemheldinconfidence.Thefollowingguidelinesaretobeappliedinmaintainingconfidentialityanddisclosinginformation.
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BreachofPrivacyandConfidentialityWhereithasbeendiscoveredorreportedthattheconfidentialityandprivacyof[AGENCY]programparticipantsand/orbusinesshasbeenbreached,thiswillresultinanimmediateconferencewiththepeermentorandtheappropriate[AGENCY]programsupervisortodiscussthenatureofthebreach,consequencesandtheappropriatenessofcontinuingtheplacement.
ExamplesofBreachesofPrivacyandConfidentiality• Accessinginformationthatyoudonotneedtoknowtodoyourjob,i.e.,unauthorizedreadingofprogramparticipantfiles.
• Lending[AGENCY]keystoprogramparticipantssothattheycanaccessotherareasofthebuilding,includingofficespace.
• Sharingofyourpersonalcontactinformationorthepersonalinformationofothers(i.e.givingoutprogramparticipant’sphonenumbertootherprogramparticipantsuponrequest).
• Leavingfilestorageunlockedifitshouldbelockedwhennotinuse(ifthepeermentorhasaccess).
• Showing,telling,copying,selling,changingordisposingofconfidentialinformationthatisnotpertinenttoyourrole.
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OFFICEUSEONLY
RECEIVED:PEERSUPPORTSERVICES:OATHOFCONFIDENTIALITY
PLEASEFAXCOMPLETEDFORMTOFAX# ORSUBMITTOAGENCYADDRESS
Oath of Confidentiality I, , as a peer mentor with peer support services for the AGENCY promise that information I am privy to with relation to a person involved with peer support services will only be shared by me for consult and supervision with
v the peer support staff and their supervisors and v other AGENCY peer mentors in the peer support team meeting (under supervision of the
peer support staff or designate). In case of emergency as described below and when I cannot get a hold of the peer support staff or their supervisors, I will contact another AGENCY staff member. I understand that it is my responsibility to contact the peer support staff or other AGENCY staff members as mentioned above, immediately when:
v there are concerns about child abuse or neglect; v there is a clear risk to the safety of a third party; v there is a risk of suicide; v there is a risk of harm to the peer.
I understand that:
v Any misuse on my part of an individual’s information, intentional or unintentional, shall be considered a breach of this oath as a peer mentor of peer support services.
v This breach will be reported to the peer support staff, their supervisors and the executive director of AGENCY.
v Disciplinary action will be taken up to and including termination of my enrolment as a peer mentor of peer support services.
Peer Mentor
Date
x
Peer Support Staff
Date
x
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CodeofEthics
Board,staff,volunteersandstudentsthatprovideservicesonbehalfofthe[AGENCY]areaccountabletothepeopletheyserveandtothisagency.Thisaccountabilityisachievedbyadherencetothemissionstatement,philosophy,declarationandthepracticesdeterminedbythisagency.FailuretofulfilltheobligationsofthisCodeofEthicsmayresultindisciplinaryproceduresandappropriateconsequences.Staffmembers,volunteers,students,andboardmembersofthe[AGENCY]shallbecommittedtotheadherenceofthefollowingobligations:• Toregardthewelfareofthe[AGENCY’s]programparticipantsastheirprimary
professionalduty.
• Tonotknowinglyenterintoanintimatepersonal,includingsexual,relationshipwithanyagencyprogramparticipantwhiletheyarereceivingservicesfromtheagencyandforanappropriateperiodoftimeafterterminatingtheprofessionalrelationship.
• Tomaintainanobjective,non-possessive,non-judgmental,professionalrelationshipwithprogramparticipantsandcolleagues.
• Toactinaconscientious,diligentandefficientmannerandexhibitresponsibilityandconcernforthewellbeingofcolleaguesbynotignoringmanifestationsofillnessorunethicalconduct.
• Tostriveforcompetenceintheperformanceoftheservicesandfunctionsundertakentopromoteexcellenceinthisagencyandtofulfilltheirobligationsandresponsibilitieswithintegrity.
• Toprotecttheconfidentialityofallprofessionallyacquiredinformationandtodisclosesuchinformationonlywhenproperlyauthorizedorwhenlegallyorprofessionallyobligatedtodoso.
• Toensure[AGENCY]marketingandpromotionalmaterialsneverintentionallymisinformormisleadthepublicormisrepresent[AGENCY].
• Toensuremarketingactivitiesreflecttheintegrityofthe[AGENCY]tomaintainthesupportandtrustofthecommunity.
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• Inthematterofpersonaluseofalcoholand/orotherchemicals,toserveasapositiverolemodelforprogramparticipantsand/orcolleagues.
• Toensureoff-dutyconductdoesnotnegativelybringtheagency’sreputationintodispute.Additionally,off-dutyconductshallnotnegativelyaffecttheabilityoftheemployee/volunteertodotheirjob.
• Toremainawareofpersonalbeliefsandprejudicesandshallrefrainfromimposingthemonprogramparticipantsandcolleagues.
• Aspartoftheircommitmenttoprovidingqualityservice,toacceptresponsibilityforcontinuingtheireducationandprofessionaldevelopmentand,wheneverpossible,takeadvantageofsuchopportunities.
• Tonotuseanyauthoritygivenbytheagencyinacoercivemannertomeet
personalneedsandnotpromotedependenceofanyprogramparticipantorcolleaguebut,rather,assistotherstogrowanddeveloptheirskillsandabilities.
• Toremainawareofthepossibilityofexploitationandshallnotknowinglyengageinactivitieswhichmayexploitprogramparticipants,theirfamilies,orcolleaguesforpersonal,financialorsocialgain.
• Tomaintainarespectfulattitudetowardotheragencies.Ifstronglyopposedtothemethodsorphilosophiesofanyagency,toutilizetheappropriatelinesofcommunicationtoaddresstheissue.
• Tonotdiscriminateagainstanypersononthebasisofrace,religion,socio-economics,gender,genderidentity,sexualorientation,politicalbelief,ancestry,age,abilityormaritalstatus.
• Torefrainfrommakingunauthorizedrepresentationstooutsidebodiesinthenameofthisagency.
• Employees/volunteersmustnotsolicittheagency’sprogramparticipantsordischargedprogramparticipantsfortheirprivatepractices.
• Employees/volunteersinprivatepracticemustnottreatprogramparticipantsintheirprivatepracticewhoareeligibleforservicesfromtheagency.Employees/volunteersmustinformprogramparticipantsoftheireligibilityto
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receiveservicesattheagency.
• Whenprovidingprogramparticipantswithinformationonprivatepractitioners,alloptionsarediscussedwithnopreferencesorrecommendationsgiven.
• Employees/volunteersdonotparticipateinorganizationaldecisionsfromwhichtheycouldbenefitpersonally.
• Employees/volunteersmaynotacceptgifts/benefitsfromprogramparticipantsorotheragenciesthatmaybeperceivedtoinfluencetheirroleorrelationshipwithaprogramparticipant.
• Employeesmustreportpotentialoractualconflictofinterestsituationstotheirsupervisorwhowillreportittotheexecutivedirector.
Theexecutivedirectorhasfinalauthoritytoresolveaconflictofinterestsituation.Finalappealsmaybemadetotheboardofdirectors.
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54
CodeofConduct
RespectfulWorkplacePolicy[AGENCY]recognizestherightofallemployees,boardmembers(includingallmembersofgovernancecommittees),volunteers,contractors,donorsandgueststobetreatedwithrespectanddignity,inanenvironmentfreefromharassment.[AGENCY]shalltakesuchactionsasarenecessary,whichmayincludediscipline,respectinganemployee,trusteeorvolunteerengaginginharassment(sexualorpersonalasdefinedbelow)intheworkplace.Toconstituteharassment,behaviormayberepeatedorpersistentormaybeasingleincident.Thispolicyappliestoallpersonsrelatedtoordealingwith[AGENCY].Thisincludesemployees,boardmembers(includingallmembersofgovernancecommittees),volunteers,contractors,donorsandguestsoranyoneelsedealingwith[AGENCY].Itisaconditionofemployment,paidorunpaid;itisimperativethatthereberespectforthepersonaldignityofallpersons.Thispolicyappliesinandonall[AGENCY]premises,andwherevera[AGENCY]sanctionedeventtakesplace.Preventingharassmentiseveryone’sresponsibility.Seniormanagementandboardmembersareexpectedtoactagainstharassmentevenwithoutaformalcomplaintandemployeeandboardmembersareexpectedtoexpress
theirdisapprovaliftheyencounterharassingbehavior.“Harassment”isdefinedasconductorcommentsthatthepersonkneworoughtreasonablytohaveknownwouldbeunwelcomeandinappropriateorotherwiseoffensivetoapersonoragroupofpeopleandthathavetheeffectofcreatinganintimidating,hostile,embarrassingoroffensiveworkenvironment.Theaccusedharasser’sintenthaslittlebearing;theimpactoftheactiswhatisconsidered.Harassmentincludessexualharassment,personalharassmentandabuseofauthority.Harassmentcanoccurwithacolleague,asupervisor,subordinate,volunteer,boardorboardmember,personscontractedtoworkfortheorganizationordonors/customers.Itcanoccurthroughtelecommunicationequipmentsuchasthetelephone,facsimilemachine,orcomputerterminalsintheworkplaceortheemployee’shome.Harassmentcomprisesunwelcomeorobjectionableconduct,reprisal,communication,commentsordisplaymadeoneitheraonetimeorcontinualbasisthatcouldreasonablybeexpectedtodemean,belittle,orcausepersonalhumiliationorembarrassment.
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Withoutlimitingthedefinition,harassmentasdefinedintheBritishColumbiaHumanRightsAct,isdiscriminationonthebasisofthefollowingprohibitedgrounds:
o Raceo Nationalorethnicorigino Coloro Religiono Ageo Gender/Genderidentityo Sexualorientation
o Maritalorfamilystatuso Sourceofincomeo Disabilityo Convictionforanoffensefor
whichapardonhasbeengranted
Sexualharassmentisdefinedas“anyconduct,comment,gesture,orcontactofasexualnaturethatthepersonkneworoughtreasonablytohaveknownwouldlikelycauseoffenseorhumiliationtoanyemployee,orthatmightonreasonablegroundbeperceivedbythatemployeeasplacinganimplicitorexplicitsexualconditiononemploymentopportunitiesfortraining,jobsecurity,performanceassessments,promotion,orsalaryincreases”.Sexualharassmentmayoccurintheformofbehaviorbyanygenderorgenderidentitytowardanyothergenderorgenderidentity.Harassmentandsexualharassmentincludes,butisnotlimitedto:o Abuseofauthority,whichunderminesor
threatensanemployee/volunteer’scareer.
o Writtenorverbalinsult,abuse,orthreats.o Racialorethnicslurs,includingracially
derogatorynicknames.o Unwelcomeremarks,jokes,innuendoes,
ortaunts.o Patronizing,orcondescendingbehavior,
languageorterminology,whichreinforcesstereotypesandunderminesself-respectoradverselyaffectsworkperformanceorworkingconditions.
o Displayingoffensiveordemeaningpicturesormaterial,(thisincludespicturesormaterialinprivateoffices).
o Practicaljokeswhichcauseawkwardness,embarrassment,ornegativelyaffectworkperformance.
o Unwelcomesexuallyorientedremarks,invitations,jokesorrequestswhetherindirectorexplicit.
o Leeringorobsceneoroffensivegestures.o Unwantedandinappropriatephysical
contactsuchastouching,kissing,patting,pinchingandbrushingupagainstaperson.
o Inquiriesorcommentsaboutaperson’ssexlifeorsexualpreferences.
o Differentialtreatmentbaseduponrace,gender,genderidentity,ethnicity,etc.
o Bothphysicalandpsychologicalintimidation,suchasdemeaningbehavior,andtreatingotherswithalackofrespectorgenerallycreatinganatmosphereoffear.
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Itshouldbenotedthat,whereassomebehaviormaybeoffensive,inappropriate,unwanted,oramisuseofauthority,itmaynotbeconsideredharassmentunderthelaw.Thisdoesnotmakeitacceptableat[AGENCY]andthistypeofbehaviorwillnotbetolerated.Actionsandcommentshavedifferenteffectsoneachindividual.Justbecauseonepersonmayacceptortolerateoffensivelanguage,jokesortaunting,thisshouldnotmakeanotherperson,whoisoffendedorembarrassedbythesameactionsorcomments,reluctanttoexpressorreporttheirobjections.Disciplinaryactionmayinclude:warnings,reprimands,disciplinarycounseling,negativeperformanceappraisals,withheldordelayedpromotions,suspensionwithoutpay,andtermination.
ReportingaComplaint
Ifyouare: Reportcomplaintto:
Employee/Volunteer ProgramSupervisor/Manager
Managers/SeniorManagers ExecutiveDirector(Note:IfProgramSupervisor/Manageristheharasser,reporttoExecutiveDirector.
IfExecutiveDirectoristheharasser,reporttoBoardChair)
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ProceduresforComplaints[AGENCY]encouragespromptreportingofcomplaintssothatarapidresponseandappropriateactionmaybetaken.However,becauseofthesensitivityoftheseproblemsandtheemotionaltollsuchconductmayhaveonaperson,thelatereportingofcomplaintsmaynotinitselfpreclude[AGENCY]fromtakingaction.Complaintsmaybelodgedbyapeermentor(orbytheprogramsupervisoronbehalfofapeermentor)whoisnotbeingharasseddirectly,butwhohaswitnessedorisaffectedbytheharassmentofothers.Investigationscannotbeundertakenonthebasisofananonymouscomplaint.However,whenapotentialproblemisbroughtforward,itwillnotbeignored.Thepotentialproblemwillbeactivelymonitoredandwhennecessarystepswillbetakentocorrectthesituation.Theinvestigatorhasanobligationtonotknowinglypermitorfailtotakereasonableactiontoterminatetheharassment.Anypeermentorfoundguiltyofharassmentmaybeimmediatelyremovedfromthe[AGENCY]atthediscretionoftheinvestigator.
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InformalProcessAnemployeeorvolunteerwhoexperiencesharassmentshouldfirstattempttomakeitclearlyknowntotheperson(s)responsiblethatthebehaviorisoffensiveandcontraryto[AGENCY]policyandrequestthatitstop.Theharassermaynotrealizethattheirbehaviorisunwelcomeandoffensive.Insomesituations,thismaybedifficultorinappropriateortheoffensivebehaviormaycontinueevenaftertheharasserhasbeentoldthebehaviorisoffensive.Inthiscase,thepersonbeingharassedshouldtakeimmediateactionasoutlinedbelow:• Thepersonwhoexperiencesharassmentandattemptstodealdirectlywiththe
harasser,butfails(orbelievesthatdirectapproachisinappropriate),maychoosetohavethematterdealtwithonaninformalbasiswiththeassistanceofthesupervisor(orappropriatealternate)withoutproceedingwithaformalcomplaint.Thepurposeofthisstepistoprovideameansofobtaininginformationbyvoicingtheproblemanddevelopingawaytodealwithit.Complainantsareencouragedtodiscussthesemattersdirectlywiththesupervisor,iftheyfeelthiscouldresolvetheissue.
• Anyemployeeorvolunteerwhoallows,condonesorwitnessesharassmentbuttakesnoactionorignoresacomplaintofharassmentwillbeseenaspartytotheharassment.
• Anattemptmustbemadetoresolvetheproblemwithinfivebusinessdays.• Wherethecomplainantisunsurethatharassmenthasoccurredandwouldlikehelpin
determiningwhetherornottheincidentconstitutesharassment,thecomplainantshouldimmediatelydiscusstheincidentwiththeappropriateleveloftheorganization(outlinedinthepreviouspagechart).
• Wherethecomplainantfindstheinformalresolutionoftheproblemisunsuccessful,inappropriateorunacceptable,thecomplainantmayproceedwiththeformalcomplaintprocess.
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FormalProcess:Thepersontowhomthecomplainthasbeenformallyaddressedwillinvestigateallformalcomplaints.TheymustbewrittenandsignedandshouldbedirectedtotheChair(orappropriatealternate).Thecomplaintmustincludeadescriptionoftheincident,witnesses,ifany,andstepsalreadytakenifany,toresolvethematter.1. Ifaninvestigationistobeconducted,itwillincludeinterviewswiththecomplainant,
theallegedharasser,andanywitnesses.TheChair(orappropriatealternate)willdocumentthesituationaccuratelyandcompletely.Thepartiesconcernedwillbeadvisedtheirstatementswillformapartofaconfidentialreport.Thereportwillbeavailabletothecomplainantandtheallegedharasserattheendoftheinvestigation.
2. IfthecomplainantisalsoallegingthattheChair(orappropriatealternate)hasallowed
orcondonedobservedharassment,orhasnotrespondedtoacomplaintofharassment,thismatterwillalsobeincludedintheinvestigationsandreport.
3. Thereportwillincludeallrelevantfactualinformation,acopyofthestatementsofthe
partiesconcerned,anappropriateanalysisoftheinformationincludingtheconclusionsreached,andanyrecommendations.
4. Alldecisionsmadewillbebasedonthefactsoftheincidentandnotthepersonalities
oftheparticipants.Theinvestigatormay,at[AGENCY]’sexpense,hireprofessionalassistancetodealwiththecomplaint.Thedecisionoftheinvestigatorisconsideredfinal.
5. Anattemptmustbemadetoresolvetheproblemwithintenbusinessdaysfromthe
writtencomplaintbeingpresented.Theobjectiveofaresolutionwillbetostopandpreventanyrecurrenceofharassmentand,whereappropriate,mitigatetheeffectstheharassmenthashadontheindividual.
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[AGENCY]willnot,inanyway,penalizeorretaliateagainstaboardmember,employee,volunteer,oranyoneelse,whoingoodfaithmakesacomplaintofharassment,norwill[AGENCY]permitanyoneelsetodoso.SuchactionwouldbeseriousviolationofthispolicyandshouldbereportedimmediatelytotheEDand/ortheboardchair.[AGENCY]willnottolerateanyretaliationagainstanyboardmember,employee,volunteer,oranyoneelseforhavingcomplainedofharassment,participated,orcooperatedinaninvestigationofcomplaint.Boardmembers,employeesoroperationalvolunteerswhoarefoundtohaveretaliatedmaybesubjecttodisciplinaryaction.[AGENCY]encouragesboardmembers,employeesandvolunteerstocooperateinaninvestigationofharassment.Should[AGENCY]determinethatthecomplaintwasknownbythepersonmakingthecomplainttobefalse,thismayresultindisciplinaryaction.Whilethissituationwouldnotbeexpected,makingknowinglyfalsecomplaintswouldbeconsideredaseriousdisruptiontotheworkplace.Thisisnottobeconfusedwithsituationswherethefactsareunclearorthereisalackofsupportingevidencetosupportthecomplaint.Ifthematterisnotresolvedbythe[AGENCY],anypersonmaycontacttheBritishColumbiaHumanRightsCommissiontodiscussthesituationwiththemdirectly.
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PeerMentorCodeofConduct/ConflictofInterestDeclaration
[AGENCY]endeavorstosupportpeermentorsbyprovidingopportunitiestosharetheirskills,knowledgeandtimeinsupportofourvitalwork.Peermentorsareasignificantandintegralpartofourworkingteam;consequently,theagencyhashighstandardsforpeermentorswhowishtoworkwithourprogramparticipants.AllpeermentorsareresponsibleforadheringtothepoliciesandproceduresinthePeerMentorPolicyandProcedurehandbookandallsubsequentpolicyrevisions.Peermentorsareresponsibleforpreventingrealorperceivedconflictsofinteresttoprotecttheintegrityof[AGENCY].Contravention(i.e.breach,transgressionorviolation)mayresultinarequestforapeermentortoresignand/orothersanctions.Peermentorsshall:1. Performdutieswithintegrityandinawaythatwillmaintainshareholder,publicand
member/directorconfidencein[AGENCY].2. Ensurenorealorperceivedadvantageistakenbyvirtueoftheirpositionorfrominformation
obtainedduetotheirpositionasapeermentor.3. Immediatelydisclosetothesupervisorystaffofanyexistingorpotentialconflictofintereston
anyissue.Thisdisclosurewillberecordedandsharedwiththeprogrammanager.4. Keepconfidentialallinformationpertainingtoprogramparticipants,staff,volunteersand
[AGENCY]business.Allinformationofachildprotectionnatureorsuicidalideationmustbereportedtoprogramstaffimmediately.
IdeclarethatIwillreadthePeerMentorPolicyandProcedureHandbook.Iunderstandandagreetoadheretoeverythingstatedinthehandbook,includingthisCodeofConduct/ConflictofInterestPolicy.Name:_________________________________________________________________________Signature:______________________________________________________________________Date:__________________________________________________________________________WitnessName:__________________________________________________________________WitnessSignature:_______________________________________________________________
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STORY/PHOTOCONSENTFORMPLEASEFAXCOMPLETEDFORMTOFAX# ORSUBMITTOAGENCYADDRESS
NAME
DATE:
PROJECT/DEPARTMENT
THANKYOUFORSHARINGYOURSTORY,PHOTOAND/ORWORKTOHELPUSEXTENDOURREACHAT[AGENCY]. INANEFFORTTORESPECTYOURCHOICESANDYOURCONTRIBUTIONS,PLEASELETUSKNOWHOWYOUWOULDLIKEYOURSTORY,PHOTOAND/ORWORK SHARED.
ICONSENT[AGENCY]TOUSEMY:
IMAGE/LIKENESS (PHOTOGRAPHS)q PERSONALINFORMATIONq VIDEOq WRITINGq ARTWORK
OTHER
ICONSENT[AGENCY]TOCREDITMEFORMYCONTRIBUTIONSAND/ORSTORY(DEFINEDABOVE)BY:
FULLNAME(FIRST,LAST) q FIRSTNAMEONLY q PSUEDONYM q NONAME/ANONYMOUS
ICONSENT[AGENCY]TODISPLAYMYCONTRIBUTIONSAND/ORSTORY(DEFINEDABOVE)INTHESEMEDIUMS:
PROMOTIONALPUBLICATIONS q EDUCATIONALPRESENTATIONS q MEDIA(BROADCASTS,CABLECASTS)
WEBSITE[AGENCYWEBSITE] q “INHOUSE”DISPLAY[AGENCYADDRESS(ES)]
SOCIALMEDIA(FACEBOOK,TWITTER)q OTHER
IFICHOOSETOWITHDRAWCONSENT,IWILLCONTACT[TITLE]AT[PHONENUMBER]. I UNDERSTANDTHAT[AGENCY]CANPREVENTMYCONTRIBUTIONSFROMBEINGPLACEDONTOFUTUREPUBLICATIONS,BUT CANNOTREMOVEMYCONTRIBUTIONSFROMWORKALREADYMADEPUBLIC.
BYSIGNINGBELOW,IAMAGREEINGTOCONTRIBUTETO[AGENCY]MYSTORYAND/ORPICTURESOFMYSELFTOACCOMPANYMYSTORY(DEFINEDABOVE)FORTHEPURPOSEOFINSPIRINGOTHERSTOSUPPORTTHEWORKOF[AGENCY].
NAME(PRINT)
SIGNATURE
DATE EMAIL
ADDRESS
PHONE(HOME)
POSTALCODE
PHONE(CELL)
OFFICEUSEONLY
RECEIVED:
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OFFICEUSEONLY
RECEIVED:PEERSUPPORTSERVICES:INCIDENTREPORT
PLEASEFAXCOMPLETEDFORMTOFAX# ORSUBMITTOAGENCYADDRESS
NAMEOFINDIVIDUAL DATEOFREPORT
DATEOFINCIDENT TIMEOFINCIDENT
LOCATION
NAMEOFMENTOR(PLEASEPRINT)
SIGNATUREOFMENTOR
PEERSUPPORTSTAFF(PLEASEPRINT)
SIGNATUREOFPEERSUPPORTSTAFF
CIRCUMSTANCESATTHETIMEOFTHEINCIDENT
(THISMAYBEBACKGROUNDINFORMATIONTHATCONTRIBUTEDTOTHEINCIDENT)
WHATHAPPENED(THISISAFACTUALREPORTOFWHATYOUSAWAND/ORHEARD,NOTYOURUNDERSTANDINGOROPINIONABOUTWHATHAPPENED
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WHATISAIDAND/ORDID:
OUTCOME/ACTIONTAKEN(TOBECOMPLETEDBYTHEPEERSUPPORTSTAFF,INCONSULTATIONWITHTHEMENTOR)
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PEERSUPPORTSERVICES:PROGRESSNOTES
DATE NOTES
PAGE:______________________
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OFFICEUSEONLY
RECEIVED:
[Example:Thankyouforvolunteeringasapeermentor.Inrecognitionofyourcontribution,anhonorariumwillbegivenintheformofachequeoncepermonthat$20.00perserviceeventforone-to-onementoring,groupfacilitationandpublicspeaking.Pleasenotethehonorariumisgivenperserviceeventandnotperhourofserviceprovided.]
PEERMENTORSERVICESVOLUNTEERRECORDSHEET
PLEASEFAXCOMPLETEDFORMTOFAX# ORSUBMITTOAGENCYADDRESS
NAME DATE(MONTH&YEAR)
ADDRESS
DATE SERVICE/PROGRAMPARTICIPANT VISIT#(one-to-one)
#OFHOURS
TOTALHOURS
TOTALNUMBEROFREIMBURSEDSERVICES
TOTALHONORARIUMAMOUNT $
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PEERMENTORTIMEINELIGIBLEFORHONORARIUM(meetings,trainingandotherdutiesassigned)
DATE DESCRIPTION NUMBEROF
HOURS
TOTALHOURS
TOTALMENTORHOURS(reimbursedandvolunteer)
PEERSUPPORTSTAFFSIGNATURE
DATE
PEERMENTOR SIGNATURE
DATE