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AHS / FHVS – Last Updated Apr-17
☐ Adult Volunteer ☐ Teen Volunteer ☐ Internship
Personal Information (Check Selected Program Above)
Last Name: First Name: M.I.:
Local Mailing Address:
City: State: Zip Code:
Cell Phone: Secondary Phone:
E-Mail Address:
Emergency Contact Information
Emergency Contact Name: Relationship:
Emergency Contact Phone Number:
Current / Previous Volunteer Experience
Organization: Start: End:
Organization: Start: End:
Current / Previous Work Experience
Organization: Start: End:
Organization: Start: End:
List Additional Languages (speak, read, write):
Do you currently or have you ever worked for Adventist Health System / Florida Hospital? ☐ Yes ☐ No
If yes, please explain:
Availability for Service (Select Available Times):
☐ Sunday
☐ 8 - 12☐ 12 - 4☐ 4 - 8
☐ Monday
☐ 8 - 12☐ 12 - 4☐ 4 - 8
☐ Tuesday
☐ 8 - 12☐ 12 - 4☐ 4 - 8
☐ Wednesday
☐ 8 - 12☐ 12 - 4☐ 4 - 8
☐ Thursday
☐ 8 - 12☐ 12 - 4 ☐ 4 - 8
☐ Friday
☐ 8 - 12☐ 12 - 4☐ 4 - 8
☐ Saturday
☐ 8 - 12☐ 12 - 4☐ 4 - 8
List Specific Availability:
Preferred Area of Service (List Top 3 Choices)
1. 2. 3.
Personal & Professional References (Attach with Application)
Please provide two (2) letters of reference, made out to program coordinator or manager. Letters must be signed by the person
providing the recommendation. Letters must be from an individual who is Not Related to the candidate and can attest to your
commitment and character as a volunteer. The references will need to contain contact information for each person(s) providing the
reference and will need to be provided at the time of interview (before service can begin).
Application for Volunteer Services
AHS / FHVS – Last Updated Apr-17
Parental Consent Form
I grant my consent for all of the above listed information.
Parent / Guardian Signature: _________________________________ Date: ____ / ____ / ________
Print Parent / Guardian Name: ________________________________________________________
To Be Completed by Parents / Guardians of Minors
I give permission for my son / daughter, __________________________, who is at least 16 years old, to participate as a teenage volunteer at Florida Hospital. I understand that my son / daughter is making a commitment to serve as a volunteer and that I will support his / her participation, which includes reporting for duty as scheduled, except in the event of illness, at which time proper proof will be provided from a medical professional to excuse the absence. I understand that he / she will be assigned to an available service suitable to his / her age and capabilities.
I understand that as a requirement to volunteering, my child will undergo the following: Drug Screening Tuberculosis Skin Test and / or Chest X-Ray if Appropriate Influenza Vaccination during Influenza (FLU) Season (Masks Will Be Provided if Refused) Criminal Background Screen
Influenza season starts in December and occurs through the end of March. A volunteer who has not had the influenza vaccine will be required to wear a standard facial mask while on duty, temporarily relocate selected area of service, and/or take a leave of absence from service during the Influenza season.
AHS / FHVS – Last Updated Apr-17
Acknowledgement of Information I certify that the information presented in this application is true and complete to the best of my knowledge. I
understand that any misrepresentation or omission of facts on this application will be sufficient cause for disqualification of this application.
I certify that the information presented in this application is true and complete to the best of my knowledge. Iunderstand that any misrepresentation or omission of facts on this application will be sufficient cause for disqualification of this application.
I am aware that if I should sustain injury while volunteering on a Florida Hospital campus, Florida Hospital is notliable. I understand that in the event of injury, I must report any injuries, regardless of severity, to the department inwhich I serve, and again to Volunteer Services, in order to properly document my injury.
______________________________________ _____ / _____ / __________ Volunteer Signature Date of Signature
Office Use Only Interview Date: Area of Service: Schedule:
Pledge of Commitment CONFIDENTIALITY I will consider all information confidential which I may hear directly or indirectly concerning a patient, physician
or any member of the hospital staff and I will not seek information in regard to a patient, visitor, or employee.
COMMITMENT I agree to a minimum of 100 hours to be completed within six (6) months as a volunteer with Florida
Hospital. I will uphold the standards and traditions of the hospital as they are expressed in the mission, valuesand vision presented to be prior to the application process. I will ensure to uphold said standards within the area of service to which I belong.
EXPERIENCE The purpose of the volunteer program is to provide an opportunity to experience a hospital environment and
provide needed services and assistance to the hospital staff, patients, and visitors. The program is not intendedfor the purpose of acquiring hired positions within the hospital or career training, nor is it meant to lead into a paid position with Florida Hospital.
______________________________________ _____ / _____ / __________ Volunteer Signature Date of Signature
AHS / FHVS – Last Updated Apr-17
Confidentiality Statement
System Access & Privileges
I understand access to the system needs to be protected and agree not to share access with any
unauthorized persons or individuals not affiliated with Florida Hospital.
I understand that an individual ID/Password is an electronic signature and will not intentionally use
someone else's or leave a system unattended where mine is signed-on.
Confidential Information
I understand that I may have the right to access confidential information, but will take care only to
access what I need for performing my assigned volunteer duties.
I will adhere to ethical standards in protecting confidential information both on and off campus.
I will not intentionally give out confidential information to those who don't have a legitimate need-to-
know, and I will take reasonable care to make sure that unauthorized people do not see/overhear
it, that reports are stored in a safe place, and that unneeded information is properly disposed.
I understand that any inappropriate or unauthorized retrieval/review/sharing of private patient or
employee information with unauthorized people may result in disciplinary action which could
include termination.
I will not give confidential information to anyone who is not authorized to have it.
I will not discuss confidential information when unauthorized people might overhear it.
I will not leave confidential information where unauthorized people might see it.
I will access confidential information only during my tour of duty.
I will not access confidential information which is not needed to perform specified volunteer duties.
I will not take confidential information out of my authorized work area.
I will store confidential reports in a locked, secure area.
I will destroy unnecessary confidential information by having it shredded or returned it to the area
that produced the materials.
I have read and do understand my responsibilities and obligations under this policy, and have signed my acknowledgment to adhere to its terms:
____________________________________________________ _______________________________________________ Print Applicant Name Applicant Signature
____________________________________________________ _______________________________________________ Department (for Volunteer Services only) OPT ID: (for Volunteer Services only)
Date of Signature
I will not share my personal information with unauthorized persons at any time.
_____ / _____ / __________
AHS / FHVS – Last Updated Apr-17
Privacy of Patient Information
HIPAA Acknowledgement Form (Health Insurance Portability and Accountability Act)
HIPAA is the Health Insurance Portability and Accountability Act (Federal Law) that was developed in
order to implement a national, uniform system of keeping patients records secure and private, as well
as implementing a faster way to process health care claims. Below is a brief description of important
aspects of this law that you should be aware of, even if you have not or will not deal directly with these
types of issues.
PATIENT INFORMATION
Only access, use, or disclose, on a legitimate “need to know” basis information for activities related to
treatment, payment, and healthcare operations on behalf of the company. Always maintain the privacy
of patient information. Only access, use, or disclose the minimum information necessary to perform
your designated role regardless of the extent of access provided.
NOTICE OF PRIVACY PRACTICE
Employees will provide patients with a Notice of Privacy Practices, which will inform patients of their
rights with respect to protected health information, as well as Florida Hospital’s legal responsibilities.
RELEASE OF INFORMATION
Never release information for the purposes other than treatment, payment, and healthcare operations
without written authorization from the patient, except as required by applicable federal, state, or local
laws and regulations.
I agree to abide by the HIPAA Federal law and the rules and regulations associated with patient privacy
instituted by Florida Hospital and any affiliated organizations and programs.
_______________________________________ _____________________________________
Print Applicant Name Applicant Signature
_____ / _____ / __________
Date
AHS / FHVS – Last Updated Apr-17
Volunteer Services Orientation Declaration Please complete the following declaration to ensure you understand the information presented.
This is to certify that I, __________________________________, have attended a campus orientation for Volunteer Services and received direction in the following areas concerning the policies and procedures set forth by Florida Hospital. Please mark each box to show that you understand each subject matter.
Orientation Presentations May Differ by Campus – General Information is Standard System-wide Topics Presented During Orientation Check Each Box Additional Comments Regarding Orientation
History & Legacy Mission, Vision & Values CREATION Health Patient Experience HIPAA & Confidentiality Risk Management Safety & Environment of Care Image Standards At Your Service Campus Specifics
I am aware of and understand all of the above listed items presented during the volunteer orientation. I understand that should I require additional information in relation to the volunteer program, volunteer services can provide it through the campus listed below.
_________________________________ ____________________ ____ / ____ / ____ Signature of Named Applicant Name of Selected Campus Date of Orientation
AHS / FHVS – Last Updated Apr-17
CONSENT TO OBTAIN CONSUMER REPORTS FOR PURPOSES OF VOLUNTEER SERVICES
I authorize, without reservation, any party, institution, or agency contacted by Sterling InfoSystems or this employer to furnish the above mentioned
information:
__________ / __________ / __________________ __________ / __________ / __________ __________________________________________ Selected Campus for Service Date of Birth Social Security Number
__________________________________________ ___________________________________________ ___________________________________ Last Name First Name Middle Initial
__________________________________________ ___________________________________________ ___________________________________ Alias / Previous Name E-MAIL Phone Number
__________________________________________ ___________________________________________ ___________________________________ Current Street Address City & State Zip Code
__________________________________________ ___________________________________________ ___________________________________ Previous Street Address City & State Zip Code
NOTICE TO CALIFORNIA APPLICANTS
Under Section 1786.22 of the California Civil Code, you have the right to request from Sterling, upon proper identification, the nature and substance of all
information in its files on you, including the sources of information, and the recipients of any reports on you, which Sterling has previously furnished within
the two-year period preceding your request. You may view the file maintained on you by Sterling during normal business hours. You may also obtain a
copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a
summary of your report via telephone.
NOTICE TO NEW YORK APPLICANTS
Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction
information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of the Article 23-A of the
New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses.
I hereby consent to this investigation and authorize Florida Hospital to procure a consumer report on my background as stated above from a consumer
reporting agency and/or investigative consumer reporting agency. In order to verify identify for the purposes of background identification, I am voluntarily
releasing my date of birth, social security number and other information above for my own benefit and fully understand that all decisions associated with
volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are true and correct to the
best of my knowledge. I understand that a false statement may disqualify my application for volunteer services with Florida Hospital.
__________________________________________________________________________ __________ / __________ / ___________________
Application Signature Date of Signature
__________________________________________________________________________
Parental Signature (if required)__________ / __________ / ___________________
Date of Signature
www.sterlinginfosystems.com249 West 17th Street, 6th Floor, New York, NY 10011 - Telephone: (212) 812 - 1020 | (877) 424 - 2457Fax: (646) 536 - 5239 | USCACDEN-VO2 | 05/2014
In connection with, and for the duration of, service with the organization, I understand that Florida Hospital may obtain consumer reports for placement purposes that relate to my credit, criminal, driving, employment or education history. This information will, in whole or in part, be obtained from Sterling InfoSystems Inc., Inc., 249 West 17th Street, New York, NY 10011, (800) 899 – 2272 to obtain a consumer report and/or investigative consumer report as part of the procedure for processing my application for any program affiliated with volunteer services. These reports may include information as to my general reputation, character, personal characteristics, mode of living, work habits, job performance and experience along with reasons for termination of past employment from previous employers. I understand that you may be requesting information from various federal, state, and other agencies or institutions, which maintain public and non-public records concerning my past activities relating to my driving, credit, civil, education and other experiences.
AHS / FHVS – Last Updated Apr-17
Criminal History Pre-Screening Questions
1. Have you ever been laid off, discharged from an employer or asked to resign by any employer? ☐ Yes ☐ No
2. If you answered “Yes” to the question above, please provide information on the employer, date, action and an
explanation, otherwise respond with “Not Applicable or N/A.” ☐ Not Applicable ________________________
3. Have you ever been denied a professional or occupational license, registration or certificate? ☐ Yes ☐ No
4. Has your license, registration or certificate ever been investigated, revoked, suspended, limited or subject to
discipline by any board or governing authority? ☐ Yes ☐ No
5. If you answered “Yes” to either or both of questions 3 and 4, please explain in detail. If “No,” please responded
with “Not Applicable or N/A.” ☐ Not Applicable ☐ No _____________________________________________
6. Have you ever plead guilty to any criminal offense(s) (misdemeanor or felony) other than parking tickets? If your
offense(s) have been expunged or sealed, please state “No.” ☐ Not Applicable ☐ No
7. Have you ever been convicted of any criminal offense(s) (misdemeanor or felony) other than parking tickets? If
your offense(s) have been expunged or sealed, please state “No.” ☐ Not Applicable ☐ No
8. Have you ever pled nolo contender (no contest) to any criminal offense(s) (misdemeanor or felony) other than
parking tickets? If your offense(s) have been expunged or sealed, please state “No.” ☐ Not Applicable ☐ No
9. If you answered “Yes” to any or all of questions 6, 7 and/or 8, please provide information on all criminal
offense(s), date(s), location(s) (city/state) and disposition. ☐ Not Applicable ____________________________
___________________________________________________________________________________________________
10. Have you ever served any of the following for criminal offense? (check all that apply)
☐ Pre-Trial Diversion ☐ Community Control / Supervision / Service
☐ Suspended Sentence / Prosecution ☐ Deferral / Diversion of Prosecution
☐ Shock / Challenge Incarceration ☐ Unconditional Discharge
☐ Pre-Trial Release ☐ Restorative Justice Program
☐ Supervised Release ☐ Deferred Adjudication
☐ Probation (any type) ☐ Postponed Judgement
☐ Conditional Discharge ☐ Pre-Trial Intervention
☐ Indeterminate Commitment ☐ Not Applicable
11. Any type of alternative, deferred, suspended, postponed or conditional prosecution, adjudication, disposition,
sentence, program or release not listed above, please describe: (if not, respond ☐ Not Applicable).
12. Adventist Health System facilities adhere to smoke-free environments; therefore, no smoking is permitted in or
around our facilities. If selected as a candidate, are you able to comply with these and any other additional facility-
specific smoking policies? ☐ Yes ☐ No
APPLICANT SIGNATURE: __________________________________________ DATE: _______________________ / /
H:\Auxil\AUXIL_VOLUNTEER\FORMS\General Quiz\general competency 1/26/17
General Competency Quiz
1. Code Blue Peds stands for:A. Cardiopulmonary Arrest B. Bomb threat
2. The Florida Hospital mission is toExtend the Healing Ministry ofChrist:
A. True B. False
3. Code Pink stands for:A. Infant/child Kidnapping B. A baby girl is born
4. Code Red stands for:A. Violent Incident B. Fire
5. Florida Hospital is accredited byDNV GL Healthcare:
A. True B. False
6. RACE stands for:A. Run, Avoid, Call, Evacuate B. Remove, Activate, Close,
Evacuate
7. To use a fire extinguisher, thePASS procedure is followed. Itmeans:
A. Press, Aim, Shout, Send B. Pull, Aim, Squeeze, Sweep
8. ID badges are to be worn on theupper left part of your uniform:
A. True B. False
9. The most effective method toprevent the spread of infection ishand washing:
A. True B. False
10. If requested by patients,volunteers are allowed toremove or loosen restraints:
A. True B. False
11. Accessing or sharing patientinformation can result indismissal from your volunteerposition and federal penalties:
A. True B. False
12. Volunteers can lift patients:
A. Always
B. Never
Volunteer Name: _______________________________________ Date: _____ / _____ / ________
Volunteer Signature: ____________________________________ Location: __________________
AHS / FHVS – Last Updated Apr-17
Program Competency Checklist
Please complete the below checklist to ensure program competency prior to the start of service.
Volunteer Name: Department:
TASKS TO BE COMPLETED
COMMENTS
☐
☐
☐
Can Locate & Operate Timeclocks
☐
Can Operate Timeclock System in Area of Service
☐
Knows How to Contact Department Liaison
☐
Understands Image Standards & Has Uniform & Badge
☐
Understands Cell Phone Policy for Florida Hospital
☐
Understands Non-Smoking Policy for Florida Hospital
☐
Instructed on Safety of Personal Items
☐
Demonstrates Ability to Work Independently
☐
Can Locate Public Restroom(s) in Area of Service
☐
Can Locate Campus Cafeteria and Food Service Area(s)
☐
Can Operate Wheelchairs for Patient Transport
☐
Can Locate Meal Vouchers & Knows How Use Them
Can Locate Elevators & Stairways
Can Locate Fire Alarm, Extinguisher, and Fire Exit Map
Volunteer Signature: Trainer Signature:
Date Completed: / /
I have been instructed on and comprehend all of the above listed items.