Volunteer Services Application Information
Dear Prospective Volunteer: We want to thank you for voicing an interest in volunteer work at Inspira Medical Center Vineland! Our organization places a high value on Patient Satisfaction and you can be a key part in the organization s mission to support the provision of quality, accessible, cost-effective health services that contribute to the improved health and well-being of all in the communities we serve. As a member of the Volunteer Department, you would be a part of the Guest Services team, whose mission is to be committed to providing premier service and support in an effort to improve the healthcare experience. As a volunteer, you will be able to enrich the lives of many others. Some volunteers acquire new and different skills and others bring a vast wealth of knowledge and life experience. Some volunteers will work directly with patients, families and visitors, while others will prefer to work in a variety of interesting and challenging non-patient care settings. Enclosed in this packet, you will find a listing of the types of positions that are available here at Inspira Medical Center Vineland. Attached you will find a personal checklist for becoming an official volunteer at Inspira Medical Center Vineland. You will also find an application attached to the packet. Prospective applicants who successfully meet the requirements will be scheduled for orientation and placement. If you have any questions, please call the Volunteer Department at 856-641-7738. We look forward to welcoming you as one of the newest volunteers for Inspira Medical Center Vineland! Thank you for your interest! Beth Daddario, CAVS Director Volunteers, Retail, and Guest Services Inspira Medical Center Vineland 1505 W. Sherman Avenue Vineland, NJ 08360
INSPIRA MEDICAL CENTER VINELAND VOLUNTEER SERVICES DEPARTMENT APPLICATION CHECKLIST 1. Complete Application Packet Application form, please complete pages 6-8 Reference Sheet, page 7-8, three (3) references required Consent to Photograph, Record, Videotape and/or Interview, page 9-10 Parental Consent (where indicated) Educational Skills Inventory Short Biography Signed Health Form Please note: If anything on the above checklist is not complete, the application cannot be processed. 2. Once the application is completed, we will begin to send out reference letters and the health form. As the requested information is returned, you will be notified of the next scheduled Orientation Session. 3. Attend and complete a mandatory Orientation Session. Inspira Medical Center Vineland Competency Test Confidentiality Statement Orientation Checklist Criminal Background Check TB Screening ID Photo 4. Complete TB Screening, if not done at the Orientation Session. Contact the Employee Health Department, 856-641-7595, to schedule an appointment prior to coming in for the test. TB Screening can not be administered on Thursdays. The office is open Monday Friday, 8:00 am 4:00 pm. You must return 48 hours after the test has been administered for a valid result. If you forget to have the test reviewed in 48 hours, it will be invalid and it must be repeated. This process must be completed twice to meet the Department of Health Regulations. 5. Have your picture taken for the Inspira Medical Center Vineland Identification Badge, if not done during Orientation. Please note the ID request form can be picked up at the Volunteer Department or during Volunteer Orientation. 6. Please supply the Volunteer Department with your Date of Birth and Social Security Number in order for us to complete the Sanction Review Check. 7. Consider your placement needs wishes: Assess your needs Think about what you would enjoy doing Decide how much time you have to invest Consider your current commitments Understand your own limits start slowly Be willing to try something different 8. If you have not identified your volunteer wishes during Orientation, contact Volunteer Services, 856-641-7738, to discuss further. Best of Luck!
Inspira Medical Center Vineland Volunteer Department Volunteer Opportunities Administrative Assist various departments with clerical duties such as filing, answering phones, computer work, data entry, photocopying, mailing, etc. Hours: Monday - Friday, 8:00 am - 4:30 pm Customer Service Meet and greet visitors and family members as they approach patient care areas. Escort Assist in escorting visitors from the front lobby to various departments throughout Care Center Greeter the hospital. Provide visits with patients to support the goal of patient satisfaction. Information Desk Hours: Seven days per week, 9:00 am - 8:00 pm Environmental Services Assist staff by gathering supplies and keeping the facility clean and ready for visitors. Minor cleaning as directed by staff. Hours: Monday Friday, 8:00 am - 3:00 pm Food Service Gift Shop Inspira LIFE Inspira Regional Cancer Pavilion Laundry Library (Amenities on Wheels) Assist food service staff by visiting patients with the purpose of assisting with menu selection. Assist food service staff in the kitchen with food and tray preparation as needed. Assist in delivery of trays to requested areas. Hours: Seven days per week, 9:00 am - 6:00 pm Assist staff by working in the retail area of the hospital. Meet and greet the public, working the cash register, assisting in restocking shelves, pricing new merchandise, etc. Hours: Seven days per week, 9am 8pm LIFE is a PACE program: The Program of All-inclusive Care for the Elderly serves individuals with long term care needs by providing access to the entire continuum of health care services. Volunteers assist staff by meeting and greeting participants as they arrive, assist participants with leisure pursuits either on an individual or small group basis, etc. Hours: Monday Friday, 9am 4:30pm Assist in greeting patients and directing them where they need to go, help with filing in the file room and help at the receptionist desk. Hours: Monday Friday, 8am 12pm Assist staff by delivering clean laundry throughout the facility. Hours: Monday Saturday, 8:00 am - 6:00 pm Positions available at Vineland and Bridgeton Assist by taking cart to the patient care areas to provide patients with donated reading material. Assist by maintaining the presentation of the cart in a positive way. Hours: Seven days per week, 9:00 am - 8:00 pm
Non-Clinical (Care Center) Nursing (Care Center) Nursing (ACE Program) Radiology Spiritual Care Storeroom Volunteer Center Twice Loved Treasures Thrift Store Assist staff in patient care areas with non-patient related activities such as running errands, preparing patient charts for admissions, faxing reports, answering phones, transporting patients by wheelchair as directed, etc. Hours: Seven days per week, 9:00 am - 8:00 pm Assist nursing staff with patient related services such as greeting on admission, assisting with water pitchers, visiting with patients as directed by staff, preparing tray at meal times, discharging by wheelchair as directed, and assisting with the goal of patient satisfaction. Hours: Seven days per week, 9:00 am - 8:00 pm Acute Care of the Elderly. Assist nursing staff with patient related services such as greeting on admission, assisting with water pitchers, visiting with patients as directed by staff, preparing trays at meal times, discharging by wheelchair as directed, and assisting with the goal of patient satisfaction. Hours: Seven days per week, 9:00 am - 8:00 pm Assist in greeting patients in the Radiology holding area, make sure pull cords are within reach, blankets are available and patients are comfortable while waiting. Hours: Mondays, Tuesdays, Thursdays, Fridays, 8am 6pm Assist Spiritual Care staff by providing visits to patients to offer comfort and emotional support. Hours: Seven days per week, 9:00 am - 8:00 pm Assist staff by delivering supplies to various areas of the hospital. Hours: Monday Friday, 8:00 am - 3:00 pm Assist Volunteer Department staff in a wide variety of services that range from clerical to patient services. Hours: Monday Friday, 8:00 am - 4:00 pm Assist staff by working with customers and cashier, sorting donations, maintaining stock on the sales floor, and pricing as requested. Hours: Monday Saturday, 9:30 am - 5:00 pm
Department of Volunteer Services Volunteer Application 856-641-7738 Today s Date Last Name First Name Middle Name Address City State Zip Code Home Telephone Number Cell Phone Number Business Telephone Number E-mail Address Month and Day of Birth Education/Special Training Highest Grade Level Completed Employer s Name/School s Name Parent s/guardian s Name (if under 18 yrs.) Occupation/ Academic Major Parent s/guardian s Daytime Telephone Number Are you planning a health career? Yes No If yes, in what area? Are you required to volunteer? If yes, please explain. How were you referred to IHN? Employee/Volunteer (Emp./Vol. Name) Friend/Relative Walk-In Newspaper Ad Name Internet Other, Please Explain Relatives Employed in this Facility? Yes No Name: Dept: Relationship: Have you ever been employed by IHN or its affiliates? Yes No When? Division Have you ever been convicted of a crime within the past 7 yrs? Yes No If yes, please give dates and explain. Have you ever been excluded from participation in the Medicare, Medicaid, or any other Federal Health Care Program? Yes No If yes, please explain. *Answering yes to either of these questions does not necessarily preclude you from consideration for volunteering. Do you have any health restrictions? Yes No (If yes, please explain) Personal Physician Phone #: Physician s Address: Please note: Attached to this application is a health form. We must have this health form completed by a doctor in order for you to become a volunteer. At the bottom of the health form, you will see a space for your signature. Your signature will give us permission to send this form in to your physician. Please sign it at the bottom and return it with your application. 6
Volunteer Experience: (List most recent service positions) Position: Agency: Date: Immediate Supervisor s Name/Title: Position: Agency: Date: Immediate Supervisor s Name/Title: Placement Preferences: Indicate 1 st ( ), 2 nd ( ), and 3 rd ( ) choice 1. Administrative: Administrative and clerical duties. 2. Customer Service: Meet/Greet visitors, escort to areas requested. 3. Environmental Services: Prepare area for visitors, assist with cleaning. 4. Food Service: Visit patients to assist with menu selection. 5. Gift Shop: Assist in the retail area, cashier. 6. Inspira LIFE: Assist in greeting participants as they arrive, assist participants with leisure pursuits. 7. Inspira Regional Cancer Pavilion: Assist in greeting patients and directing them where they need to go, filing. 8. Laundry: Assist in transporting clean linen to various areas in the hospital. 9. Library: Visit in-patient areas with book-cart, respond to request for material. 10. Non-Clinical: Non-clinical patient care, clerical, errands, phones, transporting 11. Nursing: Assist with patient related services, visiting, meals, discharging via wheelchair. 12. Radiology: Assist in greeting patients in the Radiology holding area, make sure patient is comfortable. 13. Spiritual Care: Provide visits for emotional support. 14. Storeroom: Deliver supplies throughout the facility. 15. Volunteer Center: Assist staff, patients, visitors. 14. Thrift Shop: Cashier, sales floor assistant, sort and price donations. 15. Other Hours and days Available to volunteer: Morning Monday Tuesday Wednesday Thursday Friday Saturday Sunday Afternoon Evening Proposed Start Date: Proposed End Date: References: List three people, other than relatives, who would be willing to serve as personal references. If you are applying for Spiritual Care, one reference must be from a Pastor/Clergy. If under 18, one reference must be a school counselor. 1. Name: Street Address: City: State: Zip Code: Email Address: 7
2. Name: Street Address: City: State: Zip Code: Email Address: 3. Name: Street Address: City: State: Zip Code: Email Address: Emergency Contact: In the event of an emergency, please list the person you would want notified. Name: Relationship: Address: Home Phone Number: Business Phone Number: Cell Phone Number: Email Address: Statement of Understanding: I certify that all information is true and has been given voluntarily. I understand that this information may be used by Inspira Medical Center Vineland for its own purposes and will be disclosed to others if required by law. I understand that I must be at least 14 years of age to volunteer at Inspira Medical Center Vineland and if I am under the age of 18 years of age I will need parental consent. Upon being offered a volunteer position, I understand that I may be required to provide additional information pertinent to the position being offered. I give permission to contact any person or organization who I have named in this application. Applicant s Signature: Date: Parental Signature: Date: Agreement I hereby commit myself to a minimum of 50 hours of volunteer service. Feel free to complete as many hours as you can. I also understand that I must complete 50 hours of service before any references can be completed on my behalf. Signature: Parental Signature (for students under 18 years of age) **Students: Please attach a copy of your last report card. 8
Date: / / I give consent for: Consent to Photograph, Record, Videotape and/or Interview Inspira Health Network to take and use photographs, audio recordings, or video of me and/or interview me for publicity, educational, marketing, advertising and fundraising purposes through internal publication, external publication, radio, television, video or internet. I understand that my name or any identifying features will not be used. [I have crossed out any purposes or media format I do not wish included.] Such photographs, audio, video and/or interview content will disclose that I have been a patient of Inspira Health Network and may contain other information about me, including private health information, what I say in the interview and facts that can be inferred from the photograph, audio, video and/or interview content. This form also may be used for IHN visitors and event participants. I understand that I am not required to sign this form in order to receive treatment or payment for my care. I understand that information used or disclosed under this authorization may be reused by Inspira Health Network and may no longer be protected by privacy regulations. I understand that I may revoke this authorization at any time by notifying Inspira Health Network in writing and the revocation will be effective on the date notified (except to the extent action has already been taken based on my earlier consent). I understand that this authorization will not expire, unless I have given written notification stating otherwise. I understand that neither I nor Inspira Health Network will receive direct or indirect payment for the communication related to this interview, photograph(s), audio recording(s) or video. I hereby release Inspira Health Network, its personnel and other persons participating in my care from any and all liability that may or could rise from the taking or the use of such interviews, photograph(s), audio recording(s) or video. I hereby waive my right to inspect or approve the final product that may be used, or to be informed of its use. Name of Patient/Subject (please print): Street Address: City, State, Zip: Telephone: Signature of Patient/Subject: Date/Time: Witness: 9
(Continued) Consent to Photograph, Record, Videotape and/or Interview Signature of parent/legal guardian/personal representative: (if patient or subject is under the age of 18 or otherwise incapable of signing) Date/Time: Relationship to patient: Witness: 10
Educational Background: o High School or Equivalent o Graduate ( College) o Undergraduate (College) o Additional Educational /Training Currently in High School Currently in College Skills/Talents/Service Inventory Please indicate the kind(s) of services/talents you can share: Clerical o Typing o Word Processing o Filing o Mailings o Answering Phones o Other Individual/Personal Services o Friendly Visiting o Transporting Patients o Direct Patient Care o Recreation o Telephone Calls o Emotional Support Community Bases Services o Translation o Special Events o Health Screenings Language Skills o Spanish o Braille o Italian o American Sign Language o French o Yiddish o Other 11
Short Biography Please use this space to tell us a little about yourself. Because filling out application for is so impersonal and volunteering is such a personal experience, this will help us to get to know you better. (You might consider the following suggestions: place of birth, family, schools, interests, hobbies, etc.) We are looking forward to talking to you in person. 12
Inspira Medical Center Vineland Department of Volunteer Services has applied for a volunteer assignment and has given your name as that of his/her personal physician. Applicant s Address: We are seeking information about the prospective volunteer s medical background to enable us to make a suitable assignment, not only for the applicant s protection, but for the protection of the patient in the hospital. This is authorization for the release of this information is on this form. Will you kindly fill out this form and return it to the Volunteer Office? A prompt reply will be appreciated. This information is treated confidentially. 1. Has the applicant had any physical or emotional illness which we should know about before making an assignment? 2. Has the applicant had any of the problems listed below which we should know about before making an assignment? A. Back Problems D. Poor Hygiene B. Tuberculosis E. Cardio-Vascular Disease C. Diabetes F. Other 3. Do you see any reason why the volunteer should not push a patient in a wheelchair? 4. To my knowledge this applicant is free from contagious disease and capable of performing volunteer assignments at Inspira Medical Center Vineland: Yes Doctor s Signature No Date I hereby authorize Dr. my personal physician to fill out the above form and return it to the Department of Volunteer Services in the enclosed envelope. If you are under 18 years old, you will need to have parental permission to have your physician complete this form. Applicant s Signature: Date Parent/Guardian Signature: Date 13