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PeerMentorHandbook 1

PeerMentorPolicyandProcedureHandbook


Index–PeerMentorPolicyandProcedureHandbook

Section Page

1.WelcometoPeerSupport5• OverviewofHandbook• About[AGENCY]

56

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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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.


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


43

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.


• 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


receiveservicesattheagency.

• Whenprovidingprogramparticipantswithinformationonprivatepractitioners,alloptionsarediscussedwithnopreferencesorrecommendationsgiven.

• Employees/volunteersdonotparticipateinorganizationaldecisionsfromwhichtheycouldbenefitpersonally.

• Employees/volunteersmaynotacceptgifts/benefitsfromprogramparticipantsorotheragenciesthatmaybeperceivedtoinfluencetheirroleorrelationshipwithaprogramparticipant.

• Employeesmustreportpotentialoractualconflictofinterestsituationstotheirsupervisorwhowillreportittotheexecutivedirector.

Theexecutivedirectorhasfinalauthoritytoresolveaconflictofinterestsituation.Finalappealsmaybemadetotheboardofdirectors.


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.


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.


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)


ProceduresforComplaints[AGENCY]encouragespromptreportingofcomplaintssothatarapidresponseandappropriateactionmaybetaken.However,becauseofthesensitivityoftheseproblemsandtheemotionaltollsuchconductmayhaveonaperson,thelatereportingofcomplaintsmaynotinitselfpreclude[AGENCY]fromtakingaction.Complaintsmaybelodgedbyapeermentor(orbytheprogramsupervisoronbehalfofapeermentor)whoisnotbeingharasseddirectly,butwhohaswitnessedorisaffectedbytheharassmentofothers.Investigationscannotbeundertakenonthebasisofananonymouscomplaint.However,whenapotentialproblemisbroughtforward,itwillnotbeignored.Thepotentialproblemwillbeactivelymonitoredandwhennecessarystepswillbetakentocorrectthesituation.Theinvestigatorhasanobligationtonotknowinglypermitorfailtotakereasonableactiontoterminatetheharassment.Anypeermentorfoundguiltyofharassmentmaybeimmediatelyremovedfromthe[AGENCY]atthediscretionoftheinvestigator.


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.


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.


[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.


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:_______________________________________________________________


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:


OFFICEUSEONLY

RECEIVED:PEERSUPPORTSERVICES:INCIDENTREPORT


NAMEOFINDIVIDUAL DATEOFREPORT

DATEOFINCIDENT TIMEOFINCIDENT

LOCATION

NAMEOFMENTOR(PLEASEPRINT)

SIGNATUREOFMENTOR

PEERSUPPORTSTAFF(PLEASEPRINT)

SIGNATUREOFPEERSUPPORTSTAFF

CIRCUMSTANCESATTHETIMEOFTHEINCIDENT

(THISMAYBEBACKGROUNDINFORMATIONTHATCONTRIBUTEDTOTHEINCIDENT)

WHATHAPPENED(THISISAFACTUALREPORTOFWHATYOUSAWAND/ORHEARD,NOTYOURUNDERSTANDINGOROPINIONABOUTWHATHAPPENED


WHATISAIDAND/ORDID:

OUTCOME/ACTIONTAKEN(TOBECOMPLETEDBYTHEPEERSUPPORTSTAFF,INCONSULTATIONWITHTHEMENTOR)


PEERSUPPORTSERVICES:PROGRESSNOTES

DATE NOTES

PAGE:______________________


OFFICEUSEONLY

RECEIVED:

[Example:Thankyouforvolunteeringasapeermentor.Inrecognitionofyourcontribution,anhonorariumwillbegivenintheformofachequeoncepermonthat$20.00perserviceeventforone-to-onementoring,groupfacilitationandpublicspeaking.Pleasenotethehonorariumisgivenperserviceeventandnotperhourofserviceprovided.]

PEERMENTORSERVICESVOLUNTEERRECORDSHEET


NAME DATE(MONTH&YEAR)

ADDRESS

DATE SERVICE/PROGRAMPARTICIPANT VISIT#(one-to-one)

#OFHOURS

TOTALHOURS

TOTALNUMBEROFREIMBURSEDSERVICES

TOTALHONORARIUMAMOUNT $


PEERMENTORTIMEINELIGIBLEFORHONORARIUM(meetings,trainingandotherdutiesassigned)

DATE DESCRIPTION NUMBEROF

HOURS

TOTALHOURS

TOTALMENTORHOURS(reimbursedandvolunteer)

PEERSUPPORTSTAFFSIGNATURE

DATE

PEERMENTOR SIGNATURE

DATE

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