Dear Prospective Volunteer: We are pleased that you are interested in becoming a volunteer, volunteen, or volunteer chaplain at Vidant Roanoke-Chowan Hospital. 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 Vidant Health 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: ______________ Only: Use Office For Vest/Shirt letter size: ___________ Please check the box to the left of the appropriate facility: ◻ Vidant Medical Center ◻ Vidant Duplin Hospital ◻ Vidant SurgiCenter ◻ Vidant Beaufort Hospital ◻ Vidant Edgecombe Hospital ◻ The Outer Banks Hospital ◻ Vidant Bertie Hospital ◻ Vidant Pungo Hospital ◻ Other___________________________________ ◻ Vidant Chowan Hospital � 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