Pacific Free Clinic Volunteer Application Dear applicant, Thank you for your interest in volunteering at Pacific Free Clinic! Pacific Free Clinic was established by students at the Stanford University School of Medicine to address the unmet health care needs of immigrants with limited English proficiency by offering free health care services and education in a linguistically and culturally appropriate manner. Our mission is: 1. To provide high-quality screening, preventive health, and referral services to medically-uninsured adults in the San Jose area; 2. To provide students interested in health professions with an educational experience that involves practicing culturally- competent preventive medicine in a low-income community setting and leading effective clinical operations. Please email this completed application and attachments to firstname.lastname@example.org AND cc it to the respective volunteer chair. Failure to cc the application to the respective volunteer chair will result in the DISQUALIFICATION of your application. DO NOT apply for more than 2 positions. The deadline to send in this application is 11:59 pm on Sunday October 17th, 2010. If you have any general questions, please email us at email@example.com. Volunteer Training & Staffing Chairs: Laboratory coordinator: Joe Carpenter (firstname.lastname@example.org) Social Referrals: Vinh Luu (email@example.com) and Tiffany Dao (firstname.lastname@example.org) Vietnamese Interpreter: Khang Dinh (email@example.com) Chinese Interpreter: Xin Shan (firstname.lastname@example.org) Spanish Interpreter: Valeria Carcamo-Cavazos (email@example.com) Front Desk: Ming Jia (firstname.lastname@example.org) VOLUNTEER POSITIONS RESPONBILITIES: Front Desk: complete patient intake protocols, including registration of patients and scheduling appointments Interpreter: provide translation services for patients and clinical staff Social Referrals: connect patients to healthcare specialty services and social services Lab Assistant: manage patient samples and lab supplies, including centrifuging and specimen delivery Requirements for application: A. Be a Stanford student or staff member. Preclinical volunteers must be Stanford students. Community members may only apply for interpreter positions. B. Commitment to PFC for at least three clinic days per academic quarter, for at least three academic quarters. C. Complete immunizations, TB testing, and HIPAA training. Responsibilities for all volunteer positions: 1. Attend the required on-campus training session on October 27th. THIS IS MANDATORY. 2. Attend the on-site training sessions in Fall 2010. 3. Volunteer at Pacific Free Clinic for three clinic days per quarter for 3 quarters for a total of 9 clinic days. Clinic days go from 8:30am to 2:30pm. APPLICATION: 1. Name: ___________________________________________________________ 2. E-mail: ________________________________________ Phone Number: _______________________ 3. I am a: ___ Stanford Undergraduate, Year: ______ ___ Stanford Graduate Student, Year: _____, Department: ____________ ___ Community Member 4. I am applying for (please rank 1-4): ___ Interpreter ___ Front Desk ___ Social Referrals ___ Lab Assistant 5. I plan to volunteer for the following quarters (mark all you can commit to): ___Fall 2010 ___Winter 2011 ___Spring 2011 ___Summer 2011 6. I am a fluent speaker of (mark all that apply, this will not impact your application): ___Spanish ___Cantonese __Mandarin ___Vietnamese ___Other (specify):________ 8. Have you volunteered for PFC before? How long and in what capacity? ______________________________ 9. Please respond to the following prompts on the next page (please be concise). a. Why did you choose to become involved at Pacific Free Clinic? b. Why are you particularly drawn to the volunteer position you are applying for? c. What past experiences or attributes will you bring to the volunteer position? d. What do you predict are your other main responsibilities for Fall 2010 – Spring 2011? 10. Please attach a copy of your immunization records, HIPAA Fundamentals Certification (HPAA-PRM-0201) completion certificate. Stanford students can access this on the Immunizations link at http://vadenpatient.stanford.edu and the Training(Stars) link at htpp://axess.stanford.edu. Please save each screenshot or html file as lastname_firstname_HIPAA and lastname_firstname_Immunizations. Please email your completed application to email@example.com as well as to your respective volunteer chair (i.e., if you are applying for social referrals as your first choice, you should email your application to firstname.lastname@example.org, email@example.com, and firstname.lastname@example.org). Your application will be reviewed in a timely manner and you will be notified on Oct. 22, 2010. I have completed this application and attached: ______ HIPAA certificate ______ Immunizations including TB screening ______ Curriculum vitae Signature ____________________________________________ Date: __________________ (Note: please type name in above space signifying understanding of the above agreement) a. Why did you choose to become involved at Pacific Free Clinic? b. Why are you particularly drawn to the volunteer position you are applying for? c. What past experiences or attributes will you bring to the volunteer position? d. What do you predict are your other main responsibilities for Spring 2010 – Fall 2010?