application for volunteer services - adventhealth · volunteer services programs are based on...

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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

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Page 1: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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

Page 2: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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.

Page 3: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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

Page 4: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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.

_____ / _____ / __________

Page 5: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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

Page 6: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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

Page 7: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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.

Page 8: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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: _______________________ / /

Page 9: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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: __________________

Page 10: Application for Volunteer Services - AdventHealth · volunteer services programs are based on legitimate non-discriminatory reasons. I hereby certify that the above statements are

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.