Please complete the application documents and them to the specified address. We look forward to adding you to our valued volunteer team!

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1 Dear Prospective Volunteer: We are excited that you have expressed an interest in volunteering at Doctors Hospital at White Rock Lake. As a volunteer, you will be providing services and support to patients, families, visitors and staff. The Volunteer Program at Doctors Hospital at White Rock Lake offers a variety of opportunities including direct and indirect patient care in a variety of locations. Please review the attached sheet describing some of the opportunities in our program. It is the goal of this office to ensure that your volunteer experience is rewarding and interesting. Please complete the application documents and them to the specified address. We look forward to adding you to our valued volunteer team! Sincerely, Kimberley Sweet Kimberley Sweet Volunteer Coordinator Doctors Hospital at White Rock Lake (office) 9440 Poppy Drive # 178 Dallas, Texas Tele: Fax:

2 Volunteer Program Volunteer Coordinator: Kimberley Sweet Phone: Areas of Volunteer Service Opportunity Patient Care Volunteers in patient care areas provide support for nursing staff with specified patient care duties, transport and delivery of patients. In addition, these volunteers also assist with administrative and clerical needs for the nursing and supervisory staff. Patient Visitor Begun in 2004, these volunteers provide social visits to patients designated by the nursing staff as needing or wanting additional visitors. Patient visitors are scheduled for weekly visitation times, and contact nursing staff upon their arrival, to identify eligible patients. They work on all patient care units. Administrative-Clerical Volunteers provide administrative and clerical support to hospital staff including copying, filing, data entry, opening and distributing incoming mail, preparing packets for mailing, answering telephones and directing calls, processing invoices for filing, file maintenance and setup and word processing. Patient Support Pastoral Care and Healing Hearts. All provide emotional and/or spiritual support for patients and their families who are dealing with impending heart procedures, amputation, or issues surrounding surgery, death or dying. Patient Support volunteers visit individual patients based on need or specific criteria. Patient Information These volunteers provide a valuable service as patient and hospital information sources for those entering the hospital and those who telephone. They provide directions to patient rooms, forward mail to discharged patients, provide limited patient information to incoming phone inquiries and other special projects, as time allows. Hospital Ambassadors assist visitors and patient families in finding their way through the hospital. Special Projects Several volunteers provide unique or specialized services to the hospital. The Craft Group creates tray favors for patient trays, decorates holiday trees for hospital staff and visitors, makes large stocking for all newborn babies to take home from the hospital and makes teddy bears for young patients in the emergency room. Other volunteers help with specialized functions such as wheelchair repair and maintenance, newsletter publishing, and defensive driving instruction for staff and volunteers.

3 PROCESS FOR VOLUNTEERING MUST COMMIT TO A MINIMUM OF 30 HOURS OF VOLUNTEER WORK 1. Complete Application Documents , fax or scan completed application documents, two letters of recommendation from teachers, pastor, ect. (Please do not include reference letters from relatives) and proof of Flu Vaccine (if applying after September 2015). 2. Interview Once all the above items have been ed, faxed or scanned you will receive a call within 1 or 2 days to schedule an interview. 3. Complete New Volunteer Health Screening A New Volunteer Health Screening must be completed prior to attending Orientation. After your interview you will be taken to our Employee Health Nurse to schedule an appointment for your TB Skin Test. On your first 1 st appointment the TB test will be given and a follow-up appointment will be scheduled at that time to have it read within 48 to 72 hours later. A parent must be present when TB Test is administered. The following documents are required New Volunteer Screening: - TB Skin Test Record and Positive PPD Questionnaire (attached for you to complete) - Proof of current Flu Vaccine if applying after September Copy of all immunizations - Copy of Past Positive TB Skin Test - Copy of Chest Xray (ONLY IF volunteer is past positive for TB Skin Test) ALL THE ABOVE REQUIREMENTS MUST BE COMPLETED BEFORE YOU ARE ALLOWED TO ATTEND ORIENTATION 4. Schedule Mandatory Orientation The first Junior Volunteer Orientation will take place on Saturday, October 17 th at 9am 2pm. If you miss this orientation, all other orientations will be held once a month on a Monday from 7:45am to 3pm. No exceptions. 5. During Orientation complete and turn in documents received, receive badge and uniform and given volunteer assignment.

4 VOLUNTEER APPLICATION 9440 Poppy Drive Dallas, Texas (214) High School Student Fall 2015 Social Security Number Application Date mm/dd/yyyy Name Birth Date Last First MI mm/dd/yyyy Other names known as/worked under Address ( ) Street City State Zip Telephone address Cell Phone ( ) Current or Former Employer Business Number ( ) Telephone Position Duties Emergency Contact ( ) Last Name First Name Relationship Telephone Education/Special Training Do you speak, read or write in a language other than English? Yes No If Yes, please describe Volunteer experience and/or community affiliations How did you hear about Doctors Hospital Volunteer Program? Why are you interested in volunteering at Doctors Hospital? What area[s] would you be interested in volunteering? Patient Care Office Other Days available Number of hours available per week Times available Please provide, along with this Application, two (2) letters of recommendation.

5 Have you ever been convicted of a felony or misdemeanor excluding traffic violations? Yes No If YES please explain: Volunteer Agreement I understand that I am applying to be a volunteer, not a paid employee, at Doctors Hospital at White Rock Lake (DH). I understand that I am authorized solely to perform tasks assigned specifically to me. I understand that I must follow all rules and regulations of DH. I understand that all information concerning DH and its patients is strictly confidential, and I hereby agree to maintain this confidentially. I understand that Doctors Hospital at White Rock Lake is not obliged to provide a volunteer placement for me, nor am I obliged to accept a volunteer position, if one is offered. I agree to accept full responsibility and to hold harmless Doctors Hospital at White Rock Lake, its employees, directors, officers or agents from any and all claims and damages that may arise from my participation in the Volunteer Program. I have read and understand the above and agree to comply with all rules and regulations of DH and the Volunteer Services Department. I understand that failure to comply with such rules and regulations may be cause for my removal from the DH Volunteer Program. I understand DH may terminate my volunteer services for any reason (or no reason) and at any time. Signature Date Remit required application and forms to one of the following: Mailing Address: Doctors Hospital at White Rock Lake 9440 Poppy Drive Attn: Volunteers Dallas, TX to Include in the subject line College Student or Adult Volunteer. Fax: Fax documents to

6 TB SKIN TEST RECORD AND POSITIVE PPD QUESTIONNAIRE NAME: DEPT/COMPANY: DOB: NEW HIRE ( ) 2-STEP ( ) ANNUAL TST ( ) ANNUAL TB QUESTIONNAIRE ( ) POST EXPOSURE ( ) DATE OF EXPOSURE The purpose of the PPD (Purified Protein Derivative) Intradermal skin test is to aid in the detection of tuberculosis or the exposure of tuberculosis. This skin test will not be considered valid until you have your skin test read within 48 to 72 hours. Call in my absence and the House Supervisor can read your results. Please answer the following confidential questions: YES NO Have you ever had tuberculosis? If so, when? Have you ever had a positive (+) reaction to the skin test? If so, when? Proof of positive result? Area of induration? mm Have you ever received the BCG vaccine? (Given in other countries to prevent TB) If so, when? Date of last CXR? Have you received any live vaccine, such as MMR, or had a viral infection in last 6 weeks? Have you taken steroids in 4 weeks? When? Have you had a cough lasting longer than 3 weeks? Have you had unexplained fever? Have you had unexplained night sweats? Have you had unintentional weight loss? Have you had unexplained loss of appetite? PARENT SIGNATURE: DATE: STUDENT SIGNATURE: DATE: ****************************************************************************************** EMPLOYEE HEALTH SECTION: Date Given: Site: RA ( ) LA ( ) Lot# Exp By: (EHN or HSup) Date Read: Result: Negative ( ) Positive ( ) mm By: (EHN or HSup) Chest x-ray requested: Result: Conversion Questionnaire: Result: Treatment: Follow-up: Revised 01/24/2014

7 VOLUNTEER SERVICES CONFIDENTIALITY NONDISCLOSURE All patient/employee/volunteer/employer group/provider/applicant/member information is considered confidential. The medical record (patient/member s chart) is a legal document. All past mental and physical histories and the care and treatment a patient/member receives, are communicated in the medical record. The information in the medical record belongs to the individuals listed above; however, the actual (hard copy) record belongs to the Tenet Health System. All health care workers or volunteers, whether directly or indirectly involved in the care of a patient/member, must use discretion when discussing patient/member information. Information obtained from Tenet Information Systems relating to the above individuals personal or medical information should not be discussed or released to anyone unless absolutely necessary for work processes. All information regarding the above individuals must be protected. Only information pertinent to the care of those persons should be communicated by appropriate personnel. Violation of this confidentiality can result in disciplinary action, up to and including termination. Additionally, release of information including test results, adoption and HIV information, without proper authorization, could result in civil and/or criminal penalties. All requests from family or friends for information should be referred to the attending physician. All other requests for information on the above individuals should be referred to Doctors Hospital at White Rock Lake Health Information Services Department. If confidential information is being discussed or otherwise inappropriately disclosed by employees or volunteers, the incident should be reported to a supervisor. Also employees and volunteer must be cognizant of where confidential information is discussed (e.g., the cafeteria, open hallways, the gift shop, elevators, etc. are inappropriate areas to be discussing confidential information). Employee or volunteer questions regarding confidentiality should be referred to the employee or volunteer s supervisor or the Director of Health Information Services. I understand that, if my job or volunteer functions require Tenet/Doctors Hospital at White Rock Lake Information Systems computer access, my computer user ID is personal and must not be shared with anyone. I agree to maintain the privacy and confidentiality of any patient, employee, volunteer, employer group, provider or Health Plan member information as it is available on the system. Signature Print Name Social Security Number Department Volunteer Services Date Rev. 20 July 2011

8 PARENT/LEGAL GUARDIAN CONSENT FOR MINOR TO PARTICIPATE IN JUNIOR VOLUNTEER PROGRAM AT DOCTORS HOSPITAL AT WHITE ROCK LAKE I (Parent/Guardian) hereby give permission for (student volunteer) to participate in the Volunteer Program at Doctors Hospital at White Rock Lake. I will fully cooperate in having him/her at the hospital on his/her assigned day and time and will notify the Volunteer Office if he/she cannot adhere to the schedule due to illness or vacation time. Signature of Parent/Legal Guardian Date PARENT/GUARDAIN CONSENT FOR MINOR TO PARTICIPATE IN EMPLOYEES HEALTH PROGRAM AT DOCTORS HOSPITAL AT WHITE ROCK LAKE I,, Parent/Legal Guardian of who is a minor and a Junior Volunteer at Doctors Hospital at White Rock Lake, give consent for my child to participate in routine employee health procedures, tests and examinations, conducted by Doctors Hospital at White Rock Lake For all employees and volunteers, including: TB skin test, Xrays (in the event that a positive reaction to TB skin test results) and Flu Shots. Child s Birth Date Date Signature of Parent/Legal Guardian Date

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