Volunteer Informed Consent, Waiver, and Release of Liability

The Northeast Medical Institute (NEMI) offers a Phlebotomy Technician Program ("the Program"), designed to prepare students for immediate employment as Phlebotomists and to further their medical assistant education.

As a core component of this Program, students receive training in drawing and collecting blood samples. To facilitate this essential practical training, volunteers are required.

If you are willing to serve as a Student Volunteer, please carefully review the information below, then sign and date where indicated at the end of this form.

Important Information Regarding the Student Volunteer Experience

The Program curriculum involves learning to draw and collect blood samples.

After a NEMI student has demonstrated proficiency in drawing fluids from inanimate objects and using training tools, they must develop practical expertise by practicing blood draws from a live subject.

All blood draws performed by NEMI students occur under the direct and close supervision of a Program instructor.

During a blood draw, the NEMI student will wear gloves and use a sterile needle, along with rubbing alcohol (70% isopropyl) or 2% iodine tincture, to ensure the puncture site is protected from bacteria. A tourniquet will then be applied. These steps are taken to ensure the safety of the Student Volunteer.

Following the blood draw, Volunteers will receive a sterile gauze pad. They should apply pressure to the site to minimize potential bruising. An adhesive strip will then be applied to hold the gauze pad in place, maintaining pressure until the bleeding at the puncture site has stopped.

Possible side effects during or immediately after the blood draw may include light-headedness, dizziness, localized pain, bruising, and/or minor swelling around the puncture site.

 

Volunteers are encouraged to drink water or other fluids the day before and the day of the practice blood draw. This helps ensure veins are fully hydrated, which can facilitate a smoother blood draw.

Informed Consent:

By signing below, I confirm that I have read and understand the information provided in this form, and I have had the opportunity to ask any questions I may have.

I hereby give my informed consent for the Volunteer named below to participate in the Program. This participation includes a blood draw performed by a NEMI Student, under the direct and close supervision of a Program instructor.

I confirm that the Volunteer named below has no medical conditions that would be adversely affected by their participation in this Program.

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Waiver of Liability and Release of Claims:

By signing below, I acknowledge and agree to the following:

I voluntarily assume all risks associated with the Volunteer's participation as a Student Volunteer in the Program.

I, along with my heirs, assigns, and representatives, hereby release, waive, discharge, hold harmless, defend, and indemnify NEMI and/or the Program, including their officers, agents, volunteers, and employees, from any and all liability, claims, demands, damages, fees, expenses, or actions. This includes any loss, damage, or injury, up to and including death, that may be sustained by the Student Volunteer as a result of their participation in the Program.

I understand that the Program cannot control all associated risks and that accidents and emergencies may occur. Therefore, I consent to any medical treatment deemed necessary by a medical professional during the Student Volunteer's participation in the Program, with the understanding that I will be financially responsible for all treatment costs.

 

I have read, understood, and voluntarily sign this Consent and Waiver and Release of Liability form.

Please contact Daniel Remiszewski, the owner of Northeast Medical Institute, if you have any questions regarding this volunteer opportunity or this form. Thank you!