Dear Prospective Volunteer:

We are pleased that you are interested in becoming a volunteer, volunteen, or volunteer chaplain at Vidant Roanoke-Chowan .

In order to expeditiously facilitate the process, I encourage you to complete the following information and return it with a copy of your most recent immunization record.

You may return it to the volunteer services office (located just past the hospital gift shop) or mail it to: Volunteer Services Department, Vidant Roanoke-Chowan Hospital, PO Box 1385, Ahoskie, NC 27910

Once the Volunteer staff receives your fully completed application, you will be contacted via email or telephone about the next steps in the application process.

Feel free to contact me anytime if you have any questions (252) 209-3290.

Sincerely,

Robin Bland Volunteer Coordinator Vidant Roanoke-Chowan Hospital [email protected]

REVISED: JULY, 2018 VOLUNTEER COMMITMENT:

* I commit to serve a minimum of one (1) year OR working sixty (60) hours at 4 hours per shift. If I am a college or high school student, I commit to provide a minimum of at least thirty (30) hours of service, working 4 hours per shift.

* It is my responsibility to get the necessary transportation to and from volunteering.

* I understand that I may be dismissed from my duties for willful wrongdoing or negligence and/or performing duties outside of my service guidelines.

* I understand that I must adhere to all the rules and regulations as outlined and reviewed during orientation/annual mandatory education sessions.

Training/Health * A volunteer orientation and health screen is required as part of the application process prior to volunteering at Vidant Roanoke-Chowan Hospital.

* All current required immunizations will be provided unless documented proof is submitted to the Occupational Health nurse.

* In order to remain active each hospital volunteer must undergo an update of the TB skin test and mandatory education annually, due by October 31st of each year - A FLU SHOT WILL ALSO BE REQUIRED DURING THE MONTH OF OCTOBER (this will be done at the annual health screen) - the volunteer coordinator will remind you to get this done. (All health screens are provided by at no cost to the volunteer.)

* Management will follow up with me in a reasonable amount of time to ensure that the placement is satisfactory.

Acknowledgement of Hospital Criminal Record Checks * Criminal record checks will be performed on every applicant volunteering at Vidant Roanoke-Chowan Hospital aged 18 and above.

* If the information that I have furnished on this form is found to be false, I could be disqualified/dismissed.

I hereby apply to become a Volunteer at Vidant Roanoke-Chowan Hospital, to abide by my commitment, to keep all patient information strictly confidential, and comply with all rules and regulations. The statements given on this application are true and accurate to the best of my knowledge.

______Applicant’s Signature Date First date started work: ______Department / Schedule: 1) ______2) ______Given to Volunteer (check off as completed): ____ Job Description ____ Uniform ____Badge ______Volgistics ID and training Date of Receipt: ______Date CBC Cleared: ______Date or Orientation: ______Date Occ Health Cleared: ______ForOffice Use Only:

Vest/Shirt letter size: ______

Please check the box to the left of the appropriate facility: ◻ ◻ ◻ Vidant SurgiCenter ◻ Vidant Beaufort Hospital ◻ Vidant Edgecombe Hospital ◻ The Hospital ◻ ◻ Vidant Pungo Hospital ◻ Other______◻ � Vidant Roanoke-Chowan Hospital VOLUNTEER SERVICES APPLICATION FOR VOLUNTEER SERVICE To The Applicant: We appreciate your interest in Vidant Health and we are sincerely interested in your qualifications to serve our patients and families. Questions on this application are asked for the sole purpose of considering you for volunteer service. We do not discriminate on the basis of race, religion, sex, national origin, age, or handicap status. A 60 hour COMMITMENT IS REQUIRED FOR SCHOOL OR JOB REFERENCE. Date:______(Circle One) Mr./ Ms. / Miss / Mrs. Name (Last) (First) (Middle) (Preferred) HOME PHONE

Present Address (number and street) BUSINESS PHONE

City, State, Zip Code CELL PHONE

OCCUPATION CELL PROVIDER

DATE OF BIRTH EMAIL ADDRESS

HAVE YOU WORKED FOR HAVE YOU WORKED HERE BEFORE? EARLIEST DATE AVAILABLE VIDANT? IF YES, WHEN?______◻NO ◻YES ◻WHEN?______

How did you hear about volunteering at VMC?______Have you previously volunteered here? ◻Yes ◻ No If so, when?______Are you currently a student? If so, where?______MISCELLANEOUS REQUIRED INFORMATION (PLEASE ANSWER ALL QUESTIONS CAREFULLY) In case of emergency, notify______(name) (relationship) (phone) Physician to contact: Dr.______(name) (phone) Describe any work-related limitations, physical or emotional______

Hobbies, Education, Skills, Interests______

Have you ever pleaded guilty or been convicted of a crime other than a minor traffic violation: ◻Yes ◻No If yes, Explain: ______

Are you related to anyone employed by us: ◻Yes ◻No If yes, give name and relationship______

If you desire to earn volunteer hours for school or another organization with a special program for credit (club, etc., we do not accept community service hours) please list:

______(organization) (reference person) (phone)

Why do you want to be a volunteer?______PLEASE CHECK ALL AREAS OF INTEREST

❑ CLERICAL ❑ RECEPTION/FAMILY WAITING ❑ PATIENT TRANSPORT ❑ NURSING ❑ OTHER______❑ NO PREFERENCE

VOLUNTEER COMMITMENT – Most volunteer positions require the volunteer to commit a minimum of four (4) hours of service once a week. Special service areas require cross-training and a commitment of a total of four (4) months. A 60 hour commitment is required for a school or job reference.

TRAINING/HEALTH – A JCAHO volunteer orientation and health screen is required before placement and cross training. An update of the health screen and JCAHO competency review is required annually. All current required immunizations will be given unless documented proof is submitted with the application.

Name:______Date:______

ACKNOWLEDGEMENT AND RELEASE: SUBSTANCE PREVENTION POLICY

I have been informed and acknowledge that Vidant Health (VH) and its subsidiary corporate entities have a Substance Abuse Prevention Policy which includes a Zero Tolerance Provision. I understand that applicants for positions with these corporations may receive pre-employment drug screening as part of the hiring process and that hiring decisions are contingent upon the results.

I specifically consent and agree to provide body fluid samples (blood and/or urine) for drug and/or alcohol screening in accordance with the policy as part of the application process.

I understand that if I am not accepted because of a positive drug screen, I will not be reconsidered for volunteer service at VH or any of its subsidiary corporate entities until I can document twelve (12) continuous months of treatment for drug abuse.

I understand and specifically consent and agree that any positive drug screening results will be furnished to the appropriate Volunteer Department and to my professional licensing board, if appropriate, I further understand that once accepted, subsequent positive screens or refusal to provide samples when requested will make me subject to disciplinary action up to and including termination. FOR OFFICE USE ONLY - NOTES:

______SIGNATURE OF VOLUNTEER

______SIGNATURE OF PARENT/GUARDIAN (If under 18 years of age)

______DATE

Application for Volunteer Services – Rev. 07/2018– VROA DISCLOSURE/AUTHORIZATION STATEMENT

By this document, Vidant Health (VH) and its subsidiary corporate entities disclose to you that a consumer report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment.

This shall authorize the procurement of a consumer report by VH and its subsidiary corporate entities as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for the appropriate corporate entity by which I am employed to procure consumer reports at any time during my employment period.

In connection with this request, I authorize all corporations, companies, former employers, supervisors, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts, motor vehicle bureaus, military services and persons to release information they may have about me to the corporate entity of Vidant Health with which this form has been filed or an agent acting on its behalf and release all parties involved from any liability and responsibility for doing so.

This authorization, in original or copy form, shall be valid for this and any future reports or updates that my be requested.

I understand that I have the right upon written request within a reasonable period of time, to request additional disclosure as to the nature and scope of the investigation.

I authorize the National Personnel Records Center, St. Louis, MO or other custodian of my military records to release to the corporate entity of VH to which I am applying or its agent acting on its behalf, information or photocopies of my military personnel and related medical records or only the following information/records:

______Applicant’s Signature Print Name (Full Name) Date

______Birth Name (Full Name) Social Security Number

______Date of Birth Driver License Number State

Military Service#:______Branch of Service:______

From:______to ______

Disclosure/Authorization Statement -Rev. 06/12 - XBS

Annual Patient-Family Advisor / Volunteer Confidentiality Statement

MEMBERSHIP APPLICATION

Mr. / Ms. / Miss / Mrs. NAME ______DATE ______

ADDRESS ______

CITY ______STATE ______ZIP ______

PHONE (HOME) ______(WORK) ______(CELL) ______

DATE OF BIRTH ______EMAIL ______

Please select the appropriate facility:

_____ _____ Vidant Beaufort Hospital _____ Vidant Home Health & Hospice _____ Vidant Bertie Hospital _____ Vidant Medical Center _____ Vidant Chowan Hospital _____ Vidant Medical Group _____ Vidant Corporate Health XXX Vidant Roanoke-Chowan Hospital _____ Vidant Duplin Hospital _____ Vidant SurgiCenter _____ Vidant Edgecombe Hospital _____ Vidant Wellness Center _____ Vidant Health (Corporate Offices) _____ Other (Be specific) ______

ADVISOR CONFIDENTIALITY STATEMENT Vidant Health has a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. In the course of my assignment at Vidant Health, I may come into possession of confidential patient information, even though I may not be directly involved in providing patient services. I understand that such information must be maintained in the strictest confidence.

• As a condition of my assignment, I hereby agree that I will not at any time during or after my assignment disclose any patient information. When patient information will be discussed with the health care practitioners in the course of my assignment, I will use discretion to assure that such conversations will not be held in a public place or with inappropriate individuals. I further agree to maintain the confidentiality of Vidant Health proprietary information or other information which I have obtained by virtue of my service as an advisor. To this end, I agree to obtain Vidant Health consent prior to the release or disclosure of any such information to third parties, specifically including members of the media.

I understand that violation of this agreement may result in termination of my assignment at Vidant Health.

______SIGNATURE OF ADVISOR / VOLUNTEER DATE

______PRINT NAME OF ADVISOR / VOLUNTEER MARKETING & ADVERTISING CONSENT WAIVER AND RELEASE

Name of person to be filmed/recorded: (print) Home address/hospital department: Email address: To be signed by the participant, parent or guardian:

I hereby give permission to University Health Systems of Eastern Carolina, Inc. d/b/a Vidant Health, and its subsidiaries and affiliated entities, including, but not limited to Pitt County Memorial Hospital, Inc. d/b/a Vidant Medical Center; Pitt Memorial Hospital Foundation, Inc. d/b/a Vidant Medical Center Foundation; University Health Systems of Eastern Carolina Foundation, Inc. d/b/a Vidant Health Foundation; HealthAccess d/b/a Vidant HealthAccess; SurgiCenter of Eastern Carolina, LLC; Vidant Medical Group, LLC; East Carolina Health, Inc. d/b/a Vidant Community ; East Carolina Health-Beaufort, Inc. d/b/a Vidant Beaufort Hospital; East Carolina Health-Bertie, Inc. d/b/a Vidant Bertie Hospital; East Carolina Health- Chowan, Inc. d/b/a Vidant Chowan Hospital; East Carolina Health-Heritage Inc. Vidant Edgecombe Hospital; East Carolina Health, Inc. d/b/a Vidant Roanoke-Chowan Hospital; Duplin General Hospital, Inc. d/b/a Vidant Duplin Hospital; The Outer Banks Hospital, Inc.; and collectively “Vidant Health entities,” to record, reproduce, publish, print, film, photograph, video, prepare, use or exhibit in any form whatsoever, including but not limited to electronically or digitally, by name, picture, image, portrait, likeness, voice, or any and all of them for the use noted below and without prior examination of the finished product.

Any picture, portrait, photograph, photo transparency, audiovisual illustration, computer file, electronic image or other likeness constitutes the property of the Vidant Health entities and may be used without prior examination of the product.

I hereby waive my rights (or my child’s rights) to privacy in connection with the consent given above and I hereby voluntarily waive, release discharge and agree to defend, indemnify and hold harmless Vidant Health entities, each of their successors, assigns, affiliates and subsidiaries; each of their directors, officers, trustees, agents and employees from any liability for any and all claims or causes of action I, my heirs or assigns might now or hereafter and further agree that this consent will not be made the basis of a future claim of any kind.

By affixing the signature below, I (print name) hereby certify that I have read and understand this CONSENT WAIVER AND RELEASE.

Signature: Date :

Witness: __ Purpose: Vidant Health Communications

Minors I am the parent or legal guardian of (print name of minor), and I hereby certify that I have read and understand this CONSENT WAIVER AND RELEASE.

Signature: Date :

Witness: Purpose:

NOT FOR USE IN PATIENT MEDICAL RECORD Marketing & Advertising Purposes Only

VH Marketing Consent & Waiver Release of Photography | Rev 10/9/2015 Criminal Record Check Form Criminal record checks will be performed on every applicant at Vidant Health (VH) or its subsidiary corporate entities. If the information you furnish on this form is found to be false, you will be disqualified/dismissed. You will not be considered for future employment/service for 18 months.

Please answer the following questions concerning your past history (Circle all that apply):

1. Have you ever been a. Convicted of a misdemeanor? Not necessary to include minor traffic infractions. Yes No b. Convicted of a worthless check(s) (if you have paid off a check at Magistrate’s office or Courthouse this is probably a worthless check conviction)? Yes No c. Convicted of any DWI’s (Driving While Impaired)? Yes No d. Convicted of violation or violations of any drug laws the Controlled Substances Act of or similar laws of any state or nation? Yes No e. Convicted of any crimes of violence such as assault, harassment, communicating threats, rape, kidnapping, manslaughter, murder? Yes No f. Convicted of a felony? Yes No g. Convicted of any crime involving child abuse, child neglect, or indecent liberties with a minor? Yes No h. Convicted of a violation or violations of a Professional Practice Act? Yes No

IF THE ANSWER TO ANY OF THE FOREGOING QUESTIONS IS “YES”, PLEASE EXPLAIN EACH CONVICTION ON THE BACK SIDE OF THIS FORM, INCLUDING COUNTY AND STATE OF CONVICTION. IF NEEDED, ADDITIONAL SHEETS ARE AVAILABLE UPON REQUEST IN THE OFFICE FROM WHICH YOU OBTAINED THIS APPLICATION.

2. Please list all names you have ever been known by including birth name, previous marriage(s), legally changed, nicknames and aliases.

(1)______(2)______

(3)______(4)______

3. Please list street, city and state where you have lived for the last ten (10) years including military and school addresses (use additional sheet if more space is needed). ______Street Street Street ______City County City County City County ______State Zip State Zip State Zip Dates Dates Dates from______to ______from______to ______from______to ______

I hereby certify that the answers on this application and this insert are true and correct, all that any misrepresentation or false information on my part will disqualify me as a candidate for employment/service, or if employed, will be grounds for discipline up to and including termination.

In connection with this request, I authorize all law enforcement agencies, city, state, county and federal courts to release information they may have about me to the corporate entity of VH to which I am applying or someone acting on their behalf.

______Signature of Applicant Date

______Print Full Name Social Security Number

______Date of Birth Valid Driver’s License Number (if you do not have license state reason)

______Current Address State where license was issued

______City State Zip

Dates: from______to ______

Date of Birth is required solely for purpose of conducting a criminal record check and will not be used for any other reason in the employment/service or application process. APPLICANT’S DISCLOSURE & AUTHORIZA TION FOR BACKGROUND SCREENING PAGE 1 OF 2

APPLICANT INFORMATION (Please Print) Account Number: 101-803550 Applicant Name: (First Middle Last) Current Address: (street address)

Other Name(s) Used: (like Maiden) City: State: Zip:

Gender: * □ □ Former Address: (1) Male Female

Social Security Number:* City: State: Zip:

Driver’s License Number.: State: Former Address: (2)

Date of Birth: * Place of Birth: (City, State, Country) City: State: Zip:

* This information will be used for purposes of background screening only and will not be used in making any employment decisions. DISCLOSURE REGARDING BACKGROUND INVESTIGATION Employer (“the Company”) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates, including motor vehicle record (or “driving record”) checks, workers compensation records, credit bureau files, employment references, personal references, social networking (i.e. Facebook, Twitter), drug screening, any educational and licensing institution or military branch and to receive any criminal record information pertaining to you which may be in the files of any federal, state or local criminal justice agency in any state. Credit reports will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. These reports may be obtained at any time after receipt of your signed authorization and, if you are hired, throughout your employment. An “investigative consumer report” includes information from personal interviews, except in California where that term means any consumer report. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067, 800-800-3774 www.infomart-usa.com or another outside organization. The scope of this disclosure and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified directly above. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which Employer shall provide within 5 days. New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that Employer has not maintained secured records is available to you upon request. Washington State applicants or employees only: Under the Washington Fair Credit Reporting Act, you have the right to ask InfoMart for a written summary of your rights. If you submit a request to Employer in writing, you have the right to get from Employer a complete and accurate disclosure of the nature and scope of the investigative consumer report Employer ordered, if any. If Employer obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

APPLICANT: Signature: Date: / /

Print Name: Fax BOTH pages to: 14680991v.2 072512 Page 1 of 2 (770) 984-8997 APPLICANT’S DISCLOSURE & AUTHORIZA TION FOR BACKGROUND SCREENING PAGE 2 OF 2

Applicant Name: (First Middle Last) Account Number: 101-803550

ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this Acknowledgement and Authorization and, if I am hired, throughout my employment. I understand that, except in California, InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067 800.800.3774 www.infomart-usa.com, and its agents, and/or another outside organization acting on behalf of Employer, and/or Employer itself may rely on this authorization to order additional consumer reports, including investigative consumer reports, from time to time during my employment, as deemed necessary for employment purposes and as allowed by law. I also authorize the following agencies and entities to disclose to InfoMart and its agents, and/or another outside organization acting on behalf of Employer, and/or Employer itself, all information about or concerning me, including, but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; insurance companies; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, drug testing results, and professional credentials and licenses. I agree that a facsimile (“fax”) or photographic copy of this Acknowledgement and Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION AND CREDIT CHECKS PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.

APPLICANT: Signature: Date: / /

Print Name: Fax BOTH pages to: (770) 984-8997

14680991v.2 072512 Page 2 of 2 Online Education Modules need to be completed and returned with the application.

(If you are reading this page on your computer, click on the link below – otherwise copy and paste it in your address bar) https://vidanthealth.learn.com/learncenter.asp?sessionid=3-A9F5ADE0-32F9-4754-9D7F- 02696DF4A722&DCT=1&id=178417&page=4

You will see a chart with many modules listed - - You only have to do the ones listed and highlighted below. Just click on the name of the module and it will open up for you to begin–

1. VH Safety Culture (includes Patient Safety Culture, EMTALA, Environment of Care) 2. VH Infection Control – Blood borne Pathogens and Tuberculosis 3. VH Infection Control – Safe Practices 4. VH Experience (includes Experience, Equity and Inclusion, Cultural Competency, Harassment, Discrimination, Workplace Bullying and Aggression, Impaired Healthcare Worker) 5. VH Advance Care Planning 6. VH HIPAA & Compliance

If these instructions are printed, GO TO www.vidanthealth.com 1) Scroll down to the very bottom of the page and click on TEAM MEMBERS 2) On the next page, under the ‘Information and resources’ section, click VOLUNTEERS 3) On the next page, over to the left, click on SHADOW 4) Scroll down to number 2. – click on education modules 5) Click on Volunteers and other non-employees 6) You will see a chart with many modules listed - - You only have to do the ones listed and highlighted above. Just click on the name of the module and it will open up for you to begin–

NOTE: The website will not retain any student information after the module is printed. If you forget to print the certificate, the module will have to be done again.

Updated 01/08/2019 VROA