TEEN VOLUNTEER PROGRAM
November 8, 2006 thru April 29th, 2007 TEEN TOWNHALL TEEN ASSIGNMENT ORIENTATION
ACADEMIC SESSION
Sunday, October 29th, 2006
9:00 AM to 3:00 PM Harvey Morse Auditorium Plaza Level, South Tower
Wednesday, Nov. 8th, 2006
3:30 PM – 5:00 PM Harvey Morse Auditorium Plaza Level, South Tower
Application Instructions To be eligible for the Teen Volunteer Program you must: 1. Be at least 14 years of age at the time of volunteering. 2. Make a commitment of 2 hours minimum per week for the duration of the Academic Session. 3. Submit all application paperwork including the health clearance requirement by October 27th, 2006. If you have questions or concerns regarding the process, please contact us so that we may help you. 4. Attend both the Teen Townhall and Teen Assignment Orientations.
NOTE: Space is limited, and will be assigned on a first-come, first-served basis.
Volunteer Coordinators: Kristofer McNeeley and Emilia Jimenez Phone: (310) 423-8044 Email: TeenVolunteerProgram@cshs.org
Registration packet available online at www.csmc.edu/293.html
VOLUNTEER SERVICES DEPARTMENT ROOM 2403 PROFESSIONAL TOWER PLAZA LEVEL 8700 BEVERLY BOULEVARD, LOS ANGELES, CALIFORNIA 90048
OFFICE (310) 423-8044
FAX (310) 423-0452
Registration Packet Contents
1. Registration Guidelines 2. General Teen Responsibilities 3. Health Requirement Instructions a) Campus Map and Health office contact information b) Health History and Evaluation (Attachment #1) c) TB Symptom Review (Attachment #2) d) Health Consent To Perform Physical Examination (Attachment 3) e) Skin Test Application From Other Facility (Attachment #4)
4. Letter of Recommendation Form 5. Teen Application 6. Confidentiality Policy Acknowledgement 7. Parental Consent to Volunteer 8. Volunteer Expectations 9. Volunteer Survey
REGISTRATION GUIDELINES Deadline: Friday, October 27th, 2006
1. Complete health requirements and receive a Health Clearance from Cedars-Sinai Employee Health Services (EHS). Please refer to the Health Requirements section of this packet for detailed instructions. (Orange colored page) 2. Submit completed and signed application paperwork to the Volunteer Office. This must include the teen’s health clearance form provided by the Employee Health Services office. 3. Parents: Please review with your teenager their schedule and choose a shift: Monday through Sunday, 2 hour segments, ranging from 9:00 AM to 9:00 PM. It is important that you take into consideration all extracurricular activities, religious commitments, or any other personal obligations before giving us your shift choice. 4. Consistency with Assignment: Please be aware that teens are expected to remain committed to the day, time and assignment for the entire session. 5. Teen Townhall * Breakfast and lunch will be served. Please let us know if teen needs kosher food. Teen uniforms will be sold during this orientation. Boys: $24 Girls: $17 Cash or checks made payable to: House of Uniforms. ID badge pictures and uniforms will be issued on the day of Townhall only to those students who have completed all application paperwork and received a health clearance.
6. Assignment Orientation *
On this day, teens meet their area supervisor, go on a tour of their assigned area and are taught about their tasks and responsibilities. All teens are required to attend this orientation in full volunteer uniform.
*Teens will receive volunteer hours for attending both orientations.
NOTE: NO PAPERWORK WILL BE PROCESSED, NOR WILL ANY HEALTH CLEARANCES WILL BE ISSUED ON THE DAY OF TEEN TOWNHALL. If you are unable to complete the health clearance by October 27th, please contact our office to make arrangements for late registration.
GENERAL TEEN RESPONSIBILITIES
Following is a general overview of non-professional responsibilities teen volunteers may perform during their assignment at the Medical Center:
1. Help patients, with supervision from the nursing personnel, to: • • • • • Talk to or read to a patient upon request Open meal trays and help patients who have no swallowing or breathing difficulty. Purchase items for patients from Gift Shop Deliver mail or flowers. Assist the patient in completion of the dietary menu for meals.
2. Answer departmental phones. 3. Assist with assembling chart forms and filing. 4. Assist with computer related work. 5. Photocopy and sort departmental papers. 6. Deliver magazines to patients or distribute magazines to various waiting room areas throughout the Medical Center. 7. Run errands between departments. 8. Assist departments in reception work, i.e. greeting visitors or patients. 9. Perform other duties and assist with projects as directed by the department supervisor or appropriate staff.
VOLUNTEER SERVICES DEPARTMENT
OFFICE 8700 BEVERLY BLVD., ROOM 2410 LOS ANGELES, CALIFORNIA 90048 (310) 423-8044 FAX (310) 423-0452
TEEN VOLUNTEER APPLICATION
Please print clearly.
(Check one) Miss Mr.
Today’s Date: Middle: Last: Name:
First Name:
Home Street Address:
City: Home Telephone: ( Work Telephone: ( Cellular Telephone: ( Are you currently employed? Employer: Describe Job Duties: ) ) )
State: Date of Birth: Social Security No: E-Mail Address: Yes (If yes, please complete information below) Address:
Postal Zip code
No
EMERGENCY INFORMATION - PLEASE LIST PARENT(S) OR GUARDIAN:
Name: Home Telephone: ( )
Relationship: Work Telephone: ( Telephone No: ( ) )
Name of Primary Physician:
Do you have any physical limitation or mental disorder that would impair your ability to perform as a volunteer in the Medical Center without any supplemental assistance? Yes No If yes, explain:
Have you ever been arrested or convicted of a crime?
Yes (If yes, please explain below)
No
(An affirmative response will not automatically disqualify you from being considered).
Name of friends and/or relatives employed or volunteering at Cedars-Sinai Health System: Name: Relationship: Department: Name: Education: Name of High School: Relationship: Department:
Graduation Year:
Name of Counselor
Email Address and/or Phone Number of Counselor:
School Activities and/or Extracurricular Activities:
Specialized Education or Training (Please list):
Personal References: ( Teachers, Counselors, Employers, Clergy, etc. - Not Family Members ) Name: Relationship: Telephone:
Name:
Relationship:
Telephone: Date
Volunteer Experience: (List current or previous volunteer activities you have been involved with): Name of Volunteer Program Type of Duties Performed 1. 2. 3. Please explain your interest in volunteering:
VOLUNTEER SHIFTS:
Shifts are in two (2) hour increments, and can be any day of the week, Monday through Sunday. Please provide two shifts for which you would be available to work. When selecting your assignment, the coordinators will choose one of the two shifts you select below. Space is limited, particularly on the weekends, therefore assignments are done on a first-come, first-served basis.
Choose two (2) shifts: one (1) Weekday and one (1) Weekend shift Circle the day of the week you are available for that shift 9:00 AM to 11:00 AM Monday 11:00 AM to 1:00 PM 1:00 PM to 3:00 PM 3:00 PM to 5:00 PM 5:00 PM to 7:00 PM 7:00 PM to 9:00 PM Monday Monday Monday Monday Monday Tuesday Tuesday Tuesday Tuesday Tuesday Tuesday Wednesday Wednesday Wednesday Wednesday Wednesday Wednesday Thursday Thursday Thursday Thursday Thursday Thursday Friday Friday Friday Friday Friday Friday Saturday Saturday Saturday Saturday Saturday Saturday Sunday Sunday Sunday Sunday Sunday Sunday
APPLICANT’S STATEMENT I hereby affirm that the information provided on this application is true and complete to the best of my knowledge, and agree to have any of the statements checked by the organization or its representatives. I understand that providing any false or misleading information or any omissions may disqualify me from further consideration as a volunteer and may result in my immediate termination even if discovered at a later date. I authorize representatives of Cedars-Sinai Medical Center to conduct a thorough investigation of my activities, and authorize all references provided in this application, as well as all other individuals, whom the Organization or its representatives may contact, to provide all information they have about me. Furthermore, I agree to cooperate in such investigation, and release from all liability or
responsibility of the Organization, all persons and entities acting on its behalf, and all persons and entities requesting or supplying such information. ______________________________ Date ________________________________________________ Signature of Applicant
Office Use Only
Assignment #1
Job Name:
TEEN - __________________________________ (SU) / (FA)
MON TUE WED THU Supervisor Name: Day(s): FRI SAT SUN Time: Tentative Start Date:
Extension
Assignment #2 Job Name:
TEEN - __________________________________ (SU) / (FA)
MON TUE WED THU Supervisor Name: Day(s): FRI SAT SUN Time: Tentative Start Date:
Extension
Assignment #3
Job Name:
TEEN - __________________________________ (SU) / (FA)
MON TUE WED THU Supervisor Name: Day(s): FRI SAT SUN Time: Tentative Start Date:
Extension
Attended VOLUNTEER ORIENTATION DATE: PAPERWORK CHECKLIST:
No call/no show Rescheduled:
ACTIVATION DATE: ASSIGNMENT ENDED (DATE): COMMENTS:
Parental Consent Volunteer Expectations Confidentiality EEO Form EHS Clearance Form Letter of Recommendation ACTIVATED BY: DEACTIVATED BY:
CONFIDENTIALITY POLICY ACKNOWLEDGEMENT I understand that I have an obligation to protect the confidentiality of Cedars-Sinai patients, business and employees, as indicated below. DEFINITIONS: 1. Confidential patient or business Information: a. Information that I may see or hear that relates to: i. PATIENTS AND/OR FAMILY MEMBERS (including employee-patients) -All information in the patient chart or other patient records, financial information, and oral communication about patients ii. VOLUNTEERS, STUDENTS, INDEPENDENT CONTRACTORS, PARTNERS – Information such as social security numbers, personal or financial information, performance records iii. BUSINESS - Information such as financial records, reports, memos, contracts, CSHS/CSMC computer programs, and technology or other information that is considered intellectual property iv. VENDORS OR OTHER THIRD PARTIES –Information such as contract terms, computer programs, and technology or other information that is considered intellectual property v. OPERATIONS IMPROVEMENT, QUALITY ASSURANCE, PEER REVIEW – Information such as reports, presentations, survey results b. CSHS personnel should discuss with their manager, director or Vice President any questions about whether specific patient or business information is considered confidential and subject to this policy. 2. Confidential Employee Information: Information created or obtained in the context of an employment application and/or an ongoing employment relationship such as salaries and wages, social security numbers, personal or financial information, or performance records, which is obtained from a Confidential Source. (Confidential Sources are CSHS sources to which access is restricted, such as employment applications, personnel files, payroll records, data banks, benefit forms or applications, computerized employee records, or information obtained from confidential employee statements or interviews). Confidential Employee Information does not include information which (i) is or becomes generally available to the public, other than as a result of a breach by CSHS Personnel of their obligations under this Policy; (ii) is or becomes available to CSHS Personnel on a non-confidential basis from a source other than CSHS; or (iii) is or becomes available because an employee voluntarily discloses such information about himself or herself to other employees or to other persons. ("Voluntary disclosure" for these purposes means disclosure freely made by an employee about himself or herself, where disclosure was not required by CSHS and was not otherwise made in order to obtain employment or any benefit of employment). I AGREE THAT: 1. I WILL ONLY initiate access of the Confidential Patient, Business or Employee Information I need to do my job. I will not disclose, discuss, or otherwise release such Confidential Patient, Business or Employee Information to others unless it is required in the performance of my job. 2. I WILL NOT show, tell, copy, give, sell, review, change, eliminate or destroy any Confidential Patient, Business or Employee Information unless it is part of my job. If it is part of my job to do any of these tasks, I will follow the correct department procedure (such as shredding confidential papers before throwing them away). 3. I WILL NOT misuse or be careless with Confidential Patient, Business or Employee Information. I WILL take appropriate precautions to avoid being overheard when discussing such Information as needed to do my job. I WILL take appropriate precautions to avoid leaving documents containing such Information out where others could view them. 4. I WILL KEEP my computer password secret and I will not share it with anyone nor will I use anyone else's password to access any CSHS/CSMC system without the express prior permission of my supervisor. Such permission will only be granted rarely and only when necessary to the performance of duties. In such cases, I understand it is my responsibility for changing my password as soon as possible. I understand that I am responsible for access or use of any information that is made using my password. 5. I WILL NOT use the CSHS/CSMC e-mail system for any purpose other than that permitted in the CSHS/CSMC e-mail policy. 6. I WILL NOT download nor transmit in any manner, Confidential Patient, Business or Employee Information unless my manager or director has given advance written approval and the downloading or transmitting is for the sole purpose of performing required work and is accomplished only in a manner consistent with CSHS security policies for electronic
7.
8. 9. 10 11. 12.
13. 14. 15. 16.
information. I understand that downloading or transmitting Confidential Patient, Business or Employee Information for any other purpose or under any other circumstances is a serious violation of my obligation. I WILL NOT share any Confidential Patient, Business or Employee Information even if I am no longer a CSHS/CSMC employee. Should I fail to comply with this, I understand I am no longer eligible for rehire at CSHS/CSMC, and may be subject to litigation or prosecution for doing so. I KNOW that my access to Confidential Patient, Business or Employee Information may be audited. I WILL tell my supervisor if I think someone knows or is using my password. I KNOW that Confidential Patient, Business or Employee Information I learn on the job does not belong to me. I KNOW that CSHS/CSMC may take away my access to Confidential Patient, Business or Employee Information and/or any CSHS/CSMC computer system at any time. I WILL protect the privacy of CSHS/CSMC employees. I will not access the Confidential Employee Information of another employee from Confidential Sources, such as employment applications, personnel files, payroll records, data banks, benefit forms or applications, computerized employee records, or information obtained from confidential employee statements or interviews unless it is part of my job to do so. I will not report, disclose or disseminate Confidential Employee Information regarding other employees, which I obtained or which I reasonably knew was obtained from a Confidential Source, unless it is part of my job to do so. I recognize that when employees are patients, their Confidential Patient Information is protected just as it is with any other patient. I WILL NOT make unauthorized copies of CSHS/CSMC's software. I AM RESPONSIBLE for my use or misuse of Confidential Patient, Business or Employee Information. I AM RESPONSIBLE for my failure to protect my password or other access to Confidential Patient, Business or Employee Information. I WILL promptly return all Confidential Patient or Business Information in my possession upon CSHS/CSMC’s request or upon termination with my relationship with CSHS/CSMC.
I understand that: 1. Failure to comply with the commitments and requirements in this acknowledgement may result in disciplinary action, up to and including termination on the first offense without prior progressive discipline, regardless of length of service with CSHS/CSMC and/or prior record of performance. 2. Accessing Confidential Patient, Business or Employee information without a need to know, whether or not any confidential information is gained through that unauthorized access or is further disclosed is a violation of this policy. 3. Failure to comply with the commitments and requirements in this acknowledgement may also result in civil or criminal legal penalties. 4. Nothing in this Acknowledgment prevents me from voluntarily disclosing information about myself and my wages, hours and working conditions to any other person or governmental agency. I further understand that nothing in this Acknowledgment prevents me from discussing information about the wages, hours and working conditions of any CSHS/CSMC employee, so long as that information was not obtained from a Confidential Source. By signing this form, I acknowledge that I am responsible for compliance with the obligations set forth in this Acknowledgement and with the Confidentiality of Patient, Business and Employee Information Policy (Admin. Policy #EBE0008) provided to me with this acknowledgement:
Signature: Last Name: First Name: Social Security Number:
Date:
Read and complete Part A and Part B. Part A requires a parent or guardian’s signature in order to participate in the Teen Volunteer Program. Part B requires a parent or guardian’s signature should an emergency arise while on duty. PART A:
Parental Consent to Volunteer
Parental consent is legally required before a child may work as a Teen Volunteer. Please sign below to give your permission for your daughter/son to serve as a teen volunteer at Cedars-Sinai Medical Center. Teen volunteer’s name Signature of parent/guardian Date
PART B:
Emergency Room Treatment and Release Form
It is legally required to obtain parental consent prior to treating a volunteer in the Emergency Room should an illness or injury occur while she/he is on volunteer duty. Please sign below to give permission to give any necessary first aid or emergency treatment should an illness or injury occur while your son/daughter is on volunteer duty. Also, please state to whom the child may be released from the Emergency Room in the event that the parent/guardian is not available. Teen volunteer’s name Signature of parent/guardian Name of alternate to whom the teen may be released Phone of alternate to whom the teen may be released Date ________________________
Volunteer Expectations
IF ACCEPTED AS A CEDARS-SINAI VOLUNTEER: 1. I shall hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients, doctors or personnel, and not seek to obtain confidential information from a patient. 2. I will donate my services to the hospital without contemplation of compensation or future employment and give my service for humanitarian and charitable purposes 3. I shall not sell or attempt to sell goods or services, request contributions or solicit persons to sign or distribute political petitions on hospital premises, unless I receive the express authorization of the Director, Volunteer Services to engage in these activities. 4. I shall submit to initial and annual health screening requirements, which may include tuberculosis screening, lab tests and/or immunizations that may be necessary as part of my service. 5. I will be punctual and conscientious, conduct myself with dignity, courtesy and consideration of others, and will endeavor to maintain professional appearance and provide quality service. 6. I will attempt to resolve any problems related to my volunteer activities with my supervisor and, if unsuccessful, attempt to resolve any such problems with the Director, Volunteer Services. 7. I will uphold the philosophy, standards and values of Cedars-Sinai Medical Center at all times in my interactions with patients, visitors, other hospital staff and volunteers. 8. I understand that the Volunteer Services Department may release me as a volunteer of the Medical Center at anytime. 9. I understand that Cedars-Sinai Medical Center assumes no responsibility for any contact, visits or services provided by me that are beyond the scope of responsibilities defined for my specific assignment. I have read and understood the Volunteer Expectations as stated above and agree to follow them in all aspects of my service to Cedars-Sinai Medical Center.
____________________________________ Volunteer Signature
__________________ Date
________________________________________ Parent/Guardian Signature if under Age 18
__________________ Date
DEPARTMENT
OF
VOLUNTEER SERVICES
PROFESSIONAL TOWER PLAZA LEVEL R O O M 2403 8700 B E V E R L Y B O U L E V A R D L O S A N G E L E S , C A L I F O R N I A 90048
OFFICE (310) 423-5231 FAX (310) 423-0452
VOLUNTEER
SURVEY
To aid Cedars-Sinai Medical Center in its commitment to Equal Opportunity and in order to provide accurate information, we ask your cooperation in completing this form. You are, however, under no obligation to do so, and your response will not affect your volunteering eligibility in any way. Any information you provide will be kept confidential. This form will be removed from your application prior to consideration for volunteering and will be used solely for statistical purposes. Today’s Date: Gender: Male Female Date of Birth:
Country of Birth:
Please check only one in this section:
American Indian or Alaskan Native Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Asian or Pacific Islander Persons having origins in any of the original peoples of the Far East, Southeast Asian, the Indian Subcontinent or the Pacific Islands. This includes, for example: China, Japan, Korea, Philippine Islands and Samoa. Black, Not of Hispanic Origin Persons having origins in any of the Black racial groups of Africa. Hispanic Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. This does not include persons of Portuguese culture or origin. White, Not of Hispanic Origin Persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
Letter of Recommendation Form
Each Cedars-Sinai Teen Volunteer needs one (1) letter of recommendation from a teacher, counselor, employer, clergy or other acquaintances (not family members). You may use this form to complete this requirement. Some of the items you might cover are: dependability, strengths, willingness to learn new things and any other items you know about this individual to help us also get to know him or her.
Name of person providing referral
Name of Teen
Relationship to Applicant
Date
Health Requirement Instructions
The Volunteer Services Department DOES NOT process any health clearances or receive any of the health form attachments. All paperwork will go with the teen to the Employee Health Services office. You will need to make an appointment with Employee Health Services (EHS) to receive clearance to volunteer. The EHS office will review all the health forms, confirm the Tuberculosis Skin Test is valid and will issue a health clearance form as proof that the teen has met all the health requirements.
STEP ONE – Making your appointment with Employee Health Services:
a) Call EHS at (310) 423-3322 to make an appointment. Space is very limited, so please make your appointment as soon as possible. The map on the reverse side of this form lists the location, phone number and office hours.
STEP TWO – What you will need to take with you to your EHS appointment:
a) Current copy of teen’s immunization records. Please check with your family physician to obtain a copy. b) Attachments 1, 2 and 3. To be completed by teen /Guardian. c) Proof of current Tuberculosis Skin Test. All volunteers MUST have a TB skin test applied and read by a physician in order to complete the health requirements and receive a health clearance from EHS. Have your physician apply the skin test, complete Attachment #4, and bring it with you to your EHS appointment. -If you do not have a private physician, EHS will administer your TB test for you free of charge. Please let them know when making your appointment. NOTE: Employee Health Services will only accept TB skin tests that were applied after April 30th, 2006.
STEP THREE – Submitting your Health Clearance Form to Volunteer Services:
a) Once EHS has issued the Health Clearance Form, submit it to the Volunteer Services Department with the rest of the registration paperwork no later than Friday, October 27th, 2006. b) If you are unable to schedule an appointment to receive a Health Clearance by October 27th, please contact our office to let us know. This will not prevent you from volunteering.
WE WILL NOT BE ABLE TO ACCEPT ANY HEALTH PAPERWORK OR ISSUE HEALTH CLEARANCE FORMS ON THE DAY OF TEEN TOWNHALL.
CEDARS-SINAI MEDICAL CENTER CAMPUS DIAGRAM 8700 Beverly Blvd., Los Angeles, CA 90048 (310) 423-5000
Employee Health Services Located: Steven Spielberg Bldg. 2nd Floor Room 200 Telephone: 310-423-3322
Hours: Mon-Wed 7am-4pm Thurs 7am-2pm Friday 7am-4pm Express Window: Mon, Thur, Fri 7:30a-8:30a Wed 7:30a-8:30a 2:30p-3:30p
Front Desk Use Only:
MRN added to Logician? EHS # in Logician Address verified? Email address listed? Dept/Mgr listed? FD initials________
PATIENT I.D.
EMPLOYEE HEALTH SERVICES HISTORY AND EVALUATION
Name:______________________________________________Dept:____________Date:____/____/___ _ Job Class: (please circle) RN Tech/Handler Admin (MA, SA) Volunteer LVN CP MD Lab/Path Surgical Tech EVS Animal
Other: __________________________
Volunteers ONLY Assignment(s):___________________________
MEDICAL REVIEW Over the past year, have you had any problems with the following that may impact your ability to perform your job? If yes, comment below Dermatologic/Skin Problems NO YES Date_______ Vision/Eye Problems NO YES Date_______ Muscle/Joint Problems (back, knee, wrist etc) NO YES Date_______ Hearing NO YES Date_______ Respiratory/Breathing NO YES Date_______ Hernias NO YES Date_______ *Heart condition NO YES Date_______ *Diabetes NO YES Date_______ *Seizure Disorder NO YES Date_______ *Surgeries NO YES Date_______ ___________________________________________________________________________________ ___________________________________________________________________________________ *Are there any medical conditions you think we should know about?____________________________ ___________________________________________________________________________________ ALLERGIES & SENSITIVITIES Do you have allergies to: Chemicals Latex *Medications NO NO NO If yes, please list and describe reaction YES ______________ Reaction_______________ YES_______________Reaction_______________ YES_______________Reaction_______________
Do you take any medications while at work or before work that could adversely affect your ability to perform your job?
*THE QUESTIONS WHICH HAVE AN * AFTER THEM ARE VOLUNTARY FOR YOU TO
ANSWER. THESE ARE NOT REQUIRED AS A CONDITION OF EMPLOYMENT, BUT MAY ASSIST US IF WE NEED TO PROVIDE YOU WITH EMERGENCY CARE.
ATTACHMENT #1
(Complete and Take with you to your Employee Health Service appointment )
COMMUNICABLE CONDITIONS Have you ever had: Chicken pox Measles Rubella Mumps Tuberculosis/+TB test NO NO NO NO NO If yes, specify dates YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________
Have you been diagnosed with any of these conditions in the past year? Hepatitis A Hepatitis B Hepatitis C Pink Eye Infectious Diarrhea Cold sores/Herpes Shingles/Zoster Scabies Boils/Skin Infection Strep Throat NO NO NO NO NO NO NO NO NO NO YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________
OCCUPATIONAL EXPOSURES Have you or will you have any contact in your job with the following: If yes, specify length time Laboratory Animals Anesthetic Gases Chemotherapy Drugs Freezers/ Cold Ethylene Oxide Formaldehyde Gluteraldehyde Lasers/Radiation Excessive Noise NO NO NO NO NO NO NO NO NO YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________ YES_________________________________
Do you currently or have you previously had any injuries or illnesses that impact your ability to perform your essential job functions? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you had any needlesticks or contaminated exposures/splashes? When and how long did you followup?__________________________________________________________________________________ _____________________________________________________________________________________ Do you wish to discuss any other health condition or problem? _____________________________________________________________________________________ _____________________________________________________________________________________ RESPIRATOR CLEARANCE Does your job entail: Patient contact? Enter patient rooms? Handle lab specimens? N/Y Exposure to ribaviran Exposure to ethylene oxide Exposure to radiation/chemo
NO NO NO NO NO NO
YES YES YES YES YES YES
If you answered yes, do you have: Heart or lung problems? N/Y Panic or claustrophobia with a respirator? N/Y Medical problems worsened with respirator? Any concerns about wearing respirator? N/Y
ATTACHMENT #1
(Complete and Take with you to your Employee Health Service appointment )
TB SYMPTOM REVIEW
Date:_________________ Volunteer Name: _____________________EHS #:___________ Volunteer Work Area: __________________________________ Ethnic Background: ___________________ D.O.B:____________ Yes 1. Have you experienced unexplained low grade fevers which persist for weeks to months? 2. Do you have night sweats? 3. Have you had a persistent cough, more than 2 weeks? 4. Do you have unexplained weight loss? 5. Do you have a lack or loss of appetite? 6. Have you ever received BCG vaccine? 7. Have you had a recent exposure to TB, or Have you had an exposure to a known TB patient since your last TB skin test? 8. Coughing up blood? 9. Have you had excessive fatigue? Signature:____________________________ Print name:___________________________ ___ ___ No ___ ___ Unknown ___ ___
___ ___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
___ ___ ___
___ ___ ___
___ ___ ___
ATTACHMENT #2
(Complete and Take with you to your Employee Health Service appointment )
PARENT must complete this form if a minor is receiving any services at Employee Health Services.
EMPLOYEE HEALTH SERVICES CONSENT TO PERFORM EMPLOYMENT PHYSICAL EXAMINATION ON A MINOR
NAME OF MINOR: I hereby grant permission for the following procedures to be performed on the minor named above as a condition of employment / volunteering at Cedars-Sinai Medical Center: General Physical Examination Tuberculosis Skin Test Vaccinations if indicated: Measles/Mumps/R ubella Hepatitis B Tetanus Toxoid Laboratory Studies: Urinalysis Complete Blood Count Hepatitis B Serology Rubella Serology Cholesterol
Printed Name of Parent or Guardian
Relationship to Minor
Signature of Parent or Guardian
Date Signed
ATTACHMENT #3
(Complete and Take with you to your Employee Health Service appointment )
SKIN TEST APPLICATION AND READING FROM FACILITY OTHER THAN CEDARS-SINAI MEDICAL CENTER Department: Volunteer Services Cedars-Sinai EHS # ____________
Employee Name: ________________________________ PRINT NAME As a part of your Employee Health annual evaluation, you have chosen to have your skin test (PPD) applied / or read at a facility other than Cedars-Sinai Medical Center. Your chosen facility is requested to follow the Cedars-Sinai Medical Center guidelines for your skin test to be acceptable. TB Antigen Test
Date Applied:_______________ 5TU Site:
Applied by:______________________R.N., M.D.
RLA LLA RUA LUA
Lot #________________________ Expiration Date:___________________________ Negative:___________mm Positive:__________mm
Read by:____________________________ R.N., M.D. Date read:__________ Does patient have a positive PPD History? _____________. If so, when did patient first test positive? ____________. What is the date of the patient’s last chest x-ray? ___________________________________________ If patient has a positive PPD history, I certify that I have screened him/her for the signs and symptoms of active tuberculosis, and the patient is free and clear of the disease. Name (print): Signature: Name of Facility: Address: Department: Telephone: ( ) ______________________________ Phone Number ATTACHMENT #4
(Have your own Physician administer the TB test, complete this form and take with you to your Employee Health Service appointment )
Area Code