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Carolinas Medical Center Consent Form Carolinas Medical Center Carolinas HealthCare System Suzanne H Freeman President

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Carolinas Medical Center Consent Form Carolinas Medical Center Carolinas HealthCare System Suzanne H Freeman President Powered By Docstoc
					                                               Carolinas Medical Center
                                                  Carolinas HealthCare System


Suzanne H. Freeman
          President




               Dear Junior Volunteer Applicant:

               Thank you for your interest in the Junior Volunteer Services program at Carolinas Medical Center.
               Joining the dedicated team of junior volunteers can be a richly rewarding experience for you.
               Through volunteering at CMC you will find challenging and enjoyable activities that will be satisfying
               to you while you perform valuable service to others. Carolinas Medical Center requires you
               participate six of the eight week program (begins June 22, 2009 and ends August 14, 2009). After
               completing this minimum commitment CMC will be happy to write a letter of recommendation and
               consider eligibility in our year round program.

               In keeping with the quality care tradition of Carolinas HealthCare System, we are committed to
               creating and maintaining excellence in all that we do. As part of the volunteer services process,
               Carolinas HealthCare system conducts a background check for all potential volunteers. We also
               require two adult references (non-relatives who are at least 21 years of age) one of which must be a
               teacher. Attached you will find an application, a list of areas to consider for your volunteer placement
               and a background permission form.

               Please complete the application, include a copy of your most recent report card indicating your un-
               weighted grade point average, and write a short essay stating why you are interested in volunteering
               at CMC and return them to the Volunteer Services Department no later than Friday, April 3, 2009.
               Please return the completed application to:
                      Carolinas Medical Center
                      Volunteer Services Department
                      PO Box 32861
                      Charlotte, NC 28232-2861
                      Fax: 704-355-7715

               Once we have processed your application and conducted an interview with you, you will be required
               to provide a health history and vaccination record (if applicable) to CMC Employee Health. Please
               complete the attached Health History form and bring it with you to your scheduled interview or you
               may fax your health information to Employee Health at 704-355-2152. If you should have questions
               regarding your health requirements contact Employee Health at 704-355-2106 during their business
               hours of 7:30am-4:30pm Monday through Friday.


               We look forward to helping you pursue your interest in volunteering at Carolinas Medical Center.

               Sincerely,



               Julie Gray, Coordinator
               Volunteer Services Department
                                 Carolinas Medical Center
                                      Volunteer Services Department
                                             Junior Volunteer

                                                 FACT SHEET


WHAT IS A HOSPITAL JUNIOR VOLUNTEER?

A Junior Volunteer is a special kind of teenager who serves the Carolinas Medical Center or healthcare facility
without remuneration, providing staff and patients a helping hand.

HOW DOES A JUNIOR VOLUNTEER SERVE AND WHY ARE THEY IMPORTANT?

Junior Volunteers make a difference in the lives of our patients and staff by helping create a warm and friendly
atmosphere for patients and their families. They provide the "extras" such as personal attention, and "service
with a smile."

Junior Volunteers also provide support to other hospital staff by helping with non-clinical duties to enhance
patient care.

WHAT ARE THE BASIC REQUIREMENTS?

Most important, a Junior Volunteer must have the desire to help and a commitment to the program
Be at least 14 years old
Have a 2.5 or better non-weighted grade point average
Parental permission and support
Completed application to include a short essay, health form, and references
Interview
Orientation to include two TB screenings and a photo ID

WHAT IS THE TIME COMMITMENT?

During the summer we require a commitment of one 3 hour shift per week: Monday-Friday 9:00am-12pm or
1pm-4:00pm.

During the school year we require a commitment of one 3 hour shift per week: Monday-Friday 4:00pm-7:00pm
or Saturday 9:00am-12:00pm or 12:00pm-3:00pm.

WHAT ARE THE REWARDS?

The rewards for a Junior Volunteer include valuable experience for future employment, job and scholarship
references, personal development, exposure to medical/healthcare careers, special awards, a new group of
friends, and the knowledge that you have the power to make a significant difference.

WHAT IS THE DRESS CODE?

All Junior Volunteers wear khaki slacks or skirt, polo shirt, and clean tennis/gym shoes. Polo shirts are
provided by Carolinas Medical Center.

For additional information, please call the Volunteer Services Department, Carolinas Medical Center at
704-355-2105.
                                               Carolinas HealthCare System
                                               Junior Volunteer Application
                                                    Carolinas Medical Center
                                                     1000 Blythe Boulevard
                                                      Charlotte NC 28203

          For volunteer opportunities with Levine Children’s Hospital Call 704-381-5053.

          Please print legibly or type

 ______________________________              ____________________________                 _______________________
   Last Name                                  First Name                                    Date

 Address________________________________ ____________________ ________________ _______________
                   Street                         City             State             Zip Code

 Home Phone (         ) ________________________Work Phone (               ) _________________________________

 e-mail address: ___________________________________________________        Birth Date________________
                                                                                         Month/Day
 Current Employer (if applicable) ____________________________________________________________________

 Your Position ________________________________________________Work Days & Hours___________________

 I have completed:    _________________Grade             Un-weighted Grade Point Average: _____________________

 Previous volunteer experience: _____________________________________________________________________
 ______________________________________________________________________________
 How did you become interested in the volunteer program? ________________________________________________
 _____________________________________________________________________________
 Please give us any other information you feel would be pertinent to your application (interests, skills, training, etc)
 ______________________________________________________________________________________________

 Reference Information: (Non-relatives who are at least 21 years of age; at least one must be a teacher) *Required

 1.    ________________________________________________________*Telephone (                   ) _____________________
            *First Name             *Last Name

     Email ______________________________________________________ Fax (                ) __________________________

     *Address ____________________________ ___________________________ _______ ______________________
              Street                            City                        State      Zip Code

2.     _________________________________________________________ *Telephone (                   ) ___________________
             *First Name             *Last Name

     Email ______________________________________________________ Fax (                ) __________________________

     *Address ____________________________ ___________________________ _______ ______________________
                  Street                         City                       State       Zip Code
Background Disclosure
CHS obtains arrest and conviction records on all potential volunteers. An arrest or conviction will not automatically
eliminate you from consideration for volunteering. However, failure to list all pending charges and/or convictions may
lead to your disqualification or termination of volunteering with CHS. Examples may include, but should not be limited
to: driving while impaired, worthless checks, assault, driving while license is suspended, disorderly conduct, credit card
fraud, embezzlement, etc.

Have you ever been convicted of any criminal violation of law, or are you now subject to a pending investigation of
charges for violation of criminal law?________
If yes, please explain ____________________________________________________________________________


Emergency Contact Information:

(1) Name____________________________________________Relationship_____________________________
   Home Phone (       ) ________________________________ Work Phone (               ) _______________________

(2) Name____________________________________________Relationship_____________________________
   Home Phone (       ) _________________________________Work Phone (               ) _______________________


TIME AVAILABLE: Please ( √ ) times available.
                 MONDAY        TUESDAY                WEDNESDAY            THURSDAY           FRIDAY
 Morning (9-12)
 Afternoon (1-4)

 As a volunteer I agree:

 I will consider as confidential all information which I may hear or see, directly or indirectly, concerning a patient,
 patient family member, doctor, or other health care professional and I will not seek information from any of the above
 in regard to a patient.

 I hereby certify that the answers on this application and any resulting from interviews are true and correct and that
 any misrepresentations or omissions of facts, misleading, or false information on my part will be grounds for
 dismissal as a volunteer. Acceptance as a volunteer is contingent upon satisfactory references, verification of
 information submitted on the application and satisfactory completion of mandatory requirements. I authorize that all employers,
 schools, or references thus contacted be released from all liability in answering questions related to my application.

 My services are donated to Carolinas HealthCare System without contemplation of compensation or future
 employment and given with humanitarian or charitable reasons.

 I give my permission for my child to serve as a Junior Volunteer at Carolinas HealthCare System and authorize
 Carolinas HealthCare System to administer emergency medical treatment to my son/daughter while volunteering.
 I understand that Junior Volunteers must be picked up promptly at the end of their scheduled shift and that
 CHS is not responsible for volunteers after their assigned volunteer shift has ended.

 ______________________________________________                        _______________________________
       Applicant's Signature                                              Date

 ______________________________________________                        _______________________________
       Parent/Guardian Signature                                          Date

                                                          **PLEASE NOTE**
  Your signature indicates your approval for us to check references. Filing an application does not assure volunteer
  placement since the number of applicants usually exceeds the number of available openings. The Volunteer Services
  Department is not obligated to provide a placement, nor are you obligated to accept the position offered. All
  applications are held for 90 days.

  The first 90 days of the volunteer experience will be mutually probationary.

  Opportunities for volunteers are provided without regard to religion, creed, race, national origin, age or sex.
                                 Carolinas Medical Center

                               Junior Volunteer Application

                                        Essay Question


Please write a short essay stating why you are interested in volunteering at CMC.
                                 Carolinas Health Care System
                               DEPARTMENT OF EMPLOYEE HEALTH
                                  CAROLINAS MEDICAL CENTER
                                     VOLUNTEER SERVICES
                                       HEALTH HISTORY


Last Name                                                  First Name
Social Security Number          -       -
Street Address                               City                         State    Zip
Home Phone (          )-         -           Birth Date      /      /     Age
In Emergency Notify
Phone (         )-         -
Personal Physician                                                        Phone
May we call your physician? □Yes     □No
Please provide dates for the following information:
                                             Had Disease          Vaccinated             Evidence of
Titer
Measles (Red)
Mumps
Rubella (German Measles)
Chicken Pox
TB Skin Test
Volunteers born in or before 1957 are considered immune (or protected) to MMR and are not subject
to the immunization.
Volunteers born after 1957 must show evidence of 2 MMR immunizations or be (re)immunized or
have a titer drawn. If the volunteer lacks proof of any MMR component (measles, mumps or rubella)
Employee Health will administer the MMR vaccine.
Volunteers in Pediatrics, Obstetrics, Nursery or Oncology must have a positive history of chickenpox,
show evidence of a positive titer or be immunized.
The information provided on this form is correct to the best of my knowledge.

__________________________________________________________________________

Volunteer Signature                                                               Date

EH Comments: _____________________________________________________________

__________________________________________________________________________
2/08
                                                         Carolinas Medical Center
                                                           Carolinas HealthCare System


Suzanne H. Freeman
          President




               Dear Parent/Guardian:

               Carolinas HealthCare System policy states that all employees and volunteers must be screened two
               (2) times for immunity to TB (tuberculosis) before beginning their assignment and yearly thereafter.
               Below is a parent permission slip for this test. Please fill out, sign, and return to the Volunteer office.
               No TB tests can be given without your permission and volunteers may not begin their assignment
               until the tests have been given.

               Employee Health nurses will administer the test prior to the first day your child volunteers. You will
               need to have them return to have the test read by the nurse 48-72 hours later. We thank you in
               advance for your support of your child's decision to be a healthy volunteer at Carolinas HealthCare
               System.

               Sincerely,


               Julie Gray, Coordinator
               Volunteer Services Department


               ---------------------------------------------------------------------------------------------------------------------

                                                               PARENT CONSENT FORM


               I give permission for ___________________________________________________ to
               receive two TB (tuberculosis) screenings. I understand that a qualified professional of the Carolinas
               Medical Center Employee Health Department will administer the test. I will bring my child to have the
               test read by the nurse on the 2nd or 3rd day after the initial test.

               Junior Volunteer Social Security Number: ____________________________________


               ________________________________________                                      _______________________
                     Parent/Guardian Signature                                                       Date
                  JUNIOR VOLUNTEER INFORMATION AND RELEASE AUTHORIZATION
                                              Terms of Volunteer Service
Because volunteer service is based on mutual consent, both CHS and you may terminate your volunteer service at any
time, for any reason, with or without cause, and without prior notice. All CHS decisions with regard to termination of
volunteer service are based on CHS policies and procedures.
CHS values integrity in the workplace. Any false or misleading representations or omissions contained in your volunteer
application may disqualify you from further consideration for volunteer services and may result in discharge even if
discovered at a later date. CHS may contact any persons and organizations named in your volunteer application to confirm
or explain the information provided.
                                        BACKGROUND VERIFICATION DISCLOSURE
As part of the volunteer services process, Carolinas HealthCare System may obtain a Consumer Report and/or an
Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996,
requires that we advise you that for purposes of volunteer services, a Consumer Report may be made which may include
information about your criminal record, credit standing, credit capacity, character, general reputation, personal
characteristics, or mode of living. Upon written request, additional information as to the nature and scope of the report, if one
is made, will be provided in the event the report contains information regarding your character, general reputation, personal
characteristics, or mode of living. Examples may include, but should not be limited to: driving while impaired, worthless
checks, assault, driving while license is suspended, disorderly conduct, credit card fraud, embezzlement, etc.

                                AUTHORIZATION, ACKNOWLEDGEMENT, AND RELEASE
During the application process and at any time during my affiliation with CHS, I hereby authorize BIB – Background
Investigation Bureau, on behalf of CHS to procure a Consumer Report which I understand may include information as
described above. This report may be compiled with information from credit bureaus, courts record repositories, departments
of motor vehicles, past or present employers and education institutions, governmental occupational licensing, or registration
entities, business or personal references, and any other source required to verify information that I have voluntarily supplied.
I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification,
to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or
mode of living.

I understand that I must report, in writing, any charge to the Volunteer Services designee by the next volunteer assignment.
I further acknowledge that failure to report a charge will be grounds for immediate termination of my participation in the
volunteer services program. I understand that I must report, in writing, any conviction or sanction to the Volunteer Services
designee within five days of the occurrence. I further acknowledge that failure to report a conviction or sanction will be
grounds for immediate termination of my participation in volunteer services program. I authorize the ongoing procurement of
the above-mentioned reports at any time during my volunteer experience.

Name: __________________________________________________________________________________
                                Last, First, Middle (Please Print)

Maiden or Other Name(s) Used: _____________________________________________________________
Social Security Number: ___________________________                              Date of Birth: __________________________
Current Address: _________________________________________________________________________
                 _________________________________________________________________________
How long have you lived at this residence? __________________
(If less than 7 years, please indicate all previous addresses during this period below. Please attach an additional sheet if needed.)

Address:
_________________________________________________________________________________
Address:
_________________________________________________________________________________
Address:
_________________________________________________________________________________
Address:
_________________________________________________________________________________

_____________________________________                         ____________________________                    _________________
Volunteer Printed Name                                        Volunteer Signature                             Date

_____________________________________                         ____________________________                    _________________
Parent/Guardian Printed Name                                  Signature                                       Date
                                     Carolinas Medical Center
                                     Volunteer Areas of Service

Carolinas Medical Center offers a variety of volunteer experiences for individuals and groups. Our
volunteers work in over 100 departments throughout the hospital. Listed below are samples of some
of the assignments, a brief description of the job, days and times in which they are available.


Dietary
Assists with cleaning and straightening of tables, chairs, table decorations and trays. Assists with
restocking and wrapping of utensils.


Emergency Department
Waiting Room: Serves as a liaison between visitors, families and patient representatives by providing
necessary information about services available and the patient’s progress.
Monday through Friday 9 a.m. to 4 p.m.

Triage: Greets visitors, may assist with registering patients into computer, assists with errands at the
direction of the staff, transports patients and escorts family members/visitors to various areas through
the hospital. Monday though Friday 9:00 a.m. to 4:00 p.m.

Major Treatment Area: Circulates around treatment rooms to ensure patient’s and family’s comfort
needs are met. May provide food, drink and warm blankets at the direction of staff.
Monday though Friday 9 a.m. to 4:00 p.m.


Flower Room
Intake: Receives and logs in all floral deliveries for patients and employees. Documents information
to ensure correct delivery. Monday through Friday 1:00 to 3:00 PM. Saturdays 12 to 2:00 p.m.

Delivery: Assists in the delivery of arrangements to patients to help brighten their day. Monday
through Saturday 1 to 4 p.m.


Gift Shop
Provides friendly and courteous service to customers while helping them select appropriate gifts and
flowers. May operate cash register and make correct change, assist staff with inventory control,
pricing, display of merchandise and inflating balloons. Monday through Friday 9:00 a.m. to 4:00 p.m.


Guest Services
Assists guest services staff with patient admissions and discharges. May escort patients, visitors and
staff to various destinations throughout the hospital. Position requires the ability to push a wheelchair
and a lot of walking. Monday through Friday 9:00 a.m. to 4:00 p.m.



Hospitality Cart
Focus on providing comfort and excellent services to eligible patients and their guests. Volunteers go
to eligible patients offering refreshments, books, magazines, and other comfort items. Afternoons
only.
Magazine Delivery
Responsible for retrieving currently dated magazines from the U.S. Post Office Forwarding Center
and delivering them to Carolinas Medical Center’s Volunteer Services Department weekly. Monday
through Friday from 9:00 a.m. to 12:00 p.m.


Nursing Unit
Provides support services of a non-clinical nature to nursing staff and patients. Duties may include
delivering ice and/or water, placing clean linens on beds after Environmental Services have cleaned
them, visiting patients and reading, writing letters, playing games or making phone calls. May also
include taking patients for walks, running errands for staff, performing clerical duties and answering
call lights. Monday through Friday 9:00 a.m. to 4:00 p.m.


Volunteer Office
Assist various areas as needed. Primary tasks include collecting and sorting WOW Cards, mailings
for varying departments, and other clerical needs.


Way-finders
Provides assistance to our guests and visitors. Volunteers are posted throughout heavily trafficked
areas to support directional and informational needs.
                            Carolinas Medical Center
                              Carolinas HealthCare System

                     Directions to Carolinas Medical Center
                             1000 Blythe Boulevard
                              Charlotte NC 28203


From I-77
•   From I-77, take I-277 East (Exit 11A southbound or Exit 11 northbound)
•   Follow the hospital “Trauma Center” signs to Kenilworth Avenue
•   Follow Kenilworth Avenue until you reach Morehead Street
•   Turn left on Morehead and follow to Kings Drive
•   Turn right on Kings Drive and follow to the first stop light at Medical Center Drive
•   Turn right on Medical Center Drive and follow signs to the Blythe Visitor’s Parking Deck


FROM I-85
•   From I-85, take the I-77 south exit
•   Stay on I-77 south until you reach Brookshire Freeway East (I-277)
•   Take Brookshire into Charlotte and exit onto John Belk Freeway
•   From John Belk Freeway, follow the hospital “Trauma Center” signs to Kenilworth Avenue
•   Follow Kenilworth Avenue until you reach Morehead Street
•   Turn left on Morehead and follow to Kings Drive
•   Turn right on Kings Drive and follow to the first stop light at Medical Center Drive
•   Turn right on Medical Center Drive and follow signs to the Blythe Visitor’s Parking Deck

				
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Description: Carolinas Medical Center Consent Form document sample