Dear Junior Volunteer Applicant,

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1 Dear Junior Volunteer Applicant, Thank you for your interest in the Junior Volunteer Program at North Shore-LIJ Southside Hospital. Southside Hospital recognizes that our volunteers are an integral part of delivering the highest quality of healthcare. Enclosed, please find the application for volunteer service. Please complete the forms and return to the Volunteer Service Department. Our office will contact you to schedule a personal interview after review of your application. Incomplete applications cannot be processed. At your interview, instructions will be given about obtaining medical clearance. Medical clearance includes a urine toxicology screening, which must be done with our Employee Health Services. A urine toxicology test is requires for all volunteers regardless of age. Your parents will be asked to give permission and sign a consent form for this test. They will also be informed of the results. You and your parent or legal guardian will be asked to attend an orientation. A junior volunteer training day will also be scheduled. Here you will learn about the opportunities and responsibilities of junior volunteers. Thank you again for your interest in our program. We look forward to meeting you. Please feel free to call our office with any questions. Sincerely, Patricia McColley Manager, Volunteer Service Department NSLIJ- Southside Hospital 301 East Main Street Bay Shore, NY Tel: (631)

2 North Shore-Long Island Jewish Health System North Shore-Long Island Jewish Health System Pre-Placement Health Assessment The New York State Department of Health (DOH) and/or North Shore LIJ Health System mandates that all persons seeking employment and/or an appointment to the Medical Staff of a hospital in the North Shore-Long Island Jewish Health System have a current physical and recorded medical history as well as documented immunity as outlined in our infection control policy. To insure your safety and the safety of our patients, all of the following requirements must be completed prior to employment or providing services. For your convenience, you can elect to have many of your exams and tests performed by either your personal physician or North Shore-LIJ Employee Health Services (EHS). Requirements include: 1. Physical examination (within last 12 months) 2. Tuberculosis Screening - this may be satisfied by either of the approved tests to detect M. tuberculosis infection: Blood based Tuberculosis Screen Tests, approved FDA test are: o QuantiFERON-TB Gold o QuantiFERON-TB Gold In-Tube o TSpot.TB OR Two-step Tuberculin Skin Testing (TST/PPD) o Provide documentation to EHS of two negative TSTs performed within the past 12 months. The 2nd TST must be within the past 3 months. OR Positive TST History o Documentation of positive TST result o A standard chest x-ray report done within the past 12 month 3. Immunizations: submit either copies of laboratory titers or proof of vaccination Rubeola (Measles) Mumps Rubella Tetanus/Diphtheria or Tetanus/Diphtheria/Pertussis Hepatitis B surface antigen and surface antibody results Varicella Vaccination documentation should include the signature of the person who administered the vaccine as well as the product and date administered 4. Urine Toxicology Screening 5. Color Vision Testing (as clinically required) 6. Respiratory Questionnaire and Fit Testing (as clinically required) 7. Latex Allergy and Sensitivity Screening If you have arranged an appointment at EHS, please complete these forms prior to your appointment and bring them with you.

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6 North Shore-Long Island Jewish Health System Screening for Allergies/ Sensitivities to North Shore-Long Island Jewish Health System Latex Products First Name: Last Name: DOB : / / Dept/Div: Title/Position Today s Date: / / Work Phone Number: ( ) - ext. 1. Do you have a history of Latex Allergy reactions?...yes No 2. Are you allergic or sensitive to foods containing...yes No bananas, avocados or chestnuts? 3. Do you develop itching, wheezing or a rash from the use of:...yes No rubber gloves or rubber bands or blowing up balloons? 4. Have you ever tested positive for a latex skin or blood test?...yes No 5. Have you ever had a prior unexplained allergic or anaphylactic reaction...yes No during a medical procedure (also known as a system reaction? latex_screening_form_ doc

7 North Shore-Long Island Jewish Health System Southside Hospital APPLICATION FOR VOLUNTEER SERVICE NS-LIJ is an Equal Opportunity Employer and a Voluntary Not-for-Profit Health System Please print in INK I am over 18 years of age I am between the ages of 14 & 18 Mr. Mrs. Ms. Last Name: First Name: Mid. Int: Today s Date: Social Security # Date of Birth: Spouse Name (if applicable) Home Address: (Street) (City/Town) (State) (Zip) Phone: Home: ( ) Phone: Business: ( ) How did you hear about the NSLIJHS Volunteer Program? Emergency contact: Foreign Language spoken: (Name) (Phone#) (Relationship) Do you have any friends or relatives employed, volunteering, or on the Board of Trustees at the NS-LIJ Health System? Yes No if yes, please provide information: Facility Department Name Relationship Did you previously work or volunteer? Yes No If Yes, please specify: (Hospital/Facility) (Dept.) (Date(s) I am currently: Employed Unemployed Retired Homemaker Student Employer s Name (if applicable): (Name) (Address) Education: High School College/Univ. Degree Business/Trade School presently attending: Major: What is your reason for volunteering? I prefer: Patient contact Non-patient contact Clerical Where needed Application for Volunteer Services 4/17/2013

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