Fall 2018 Returning Junior Volunteer Application Packet

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Rodney Roberts
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be turned in by the deadline (listed on next page): Application

1 Fall 2018 Returning Junior Volunteer Application Packet To be considered for acceptance, the following items on the checklist must be turned in by the deadline (listed on next page): Application Personal essay Completed Health Screening Form Completed Criminal History Background Form

2 Fall 2018 Important Dates The fall session runs from August 27, 2018 through December 28, We require that you miss no more than four (4) scheduled shifts during the session. If you have travel plans, a sport/extracurricular schedule, or a job that would prevent you from regular, weekly attendance please consider another organization. If you miss more than four times, you will not be invited back for the following session or receive a report of your hours. Application due date: Friday, June 29, 2018 by 4pm in the main office. **The packet must be in the Volunteer Services office by 4PM on the due date** Ways to submit your application: Hand deliver to: Volunteer Services at the MAIN CAMPUS Building F Mail to: Cincinnati Children s Hospital Medical Center Volunteer Services, MLC Burnet Avenue Cincinnati, OH ***HAND DELIVERY RECOMMENDED*** ***All postal mail including FedEx overnight, etc. goes to the hospital mailroom for processing rather than directly to our office. Therefore, please plan accordingly. To be eligible, applications must be in the Volunteer Office at the Main Campus by 4pm on Friday, June 29, 2018.*** PLAN TO CHECK YOUR THE WEEK AFTER THE APPLICATION DUE DATE TO FIND OUT IF YOU VE BEEN ACCEPTED. Mandatory orientation: We will send you the information to complete this online after your interview.

3 Dear Returning Applicant, Thank you for your interest in returning to the Junior Volunteer Program at Cincinnati Children s Hospital Medical Center. As we are sure you remember, there is a tremendous interest in volunteering, therefore we often receive more applications than we can accept. Our goal is to provide the most qualified candidates with placement that is satisfying to them as a volunteer while being helpful to our patients, families and staff. With this in mind, please consider the following guidelines. As a returning Junior Volunteer, are you able to: 1. Volunteer the same time/day each week for a 2 to 3 hour shift? Most availability is Monday through Friday. We have very limited weekend opportunities. 2. Volunteer the duration of the session, missing no more than four (4) scheduled shifts (dates listed on previous page)? 3. Come for an interview between July 2, 2018 and August 17, 2018? 4. Complete a mandatory online orientation? If you can meet these guidelines we look forward to receiving your application packet. If your packet is only partially complete it will not be considered for acceptance. Thank you, Volunteer Services Staff Amy Biersack, Director Jess Obert, Volunteer Specialist Main Campus Molly Gilbert, Volunteer Specialist Liberty Campus Juli Kiefer, Volunteer Coordinator

4 Received Interview CINCINNATI CHILDREN S HOSPITAL MEDICAL CENTER Fall 2018 Returning Junior Volunteer Application Date: Name: Social Security Number: (MANDATORY) Address: (House #) (Street) (City) (State) (Zip) Applicant s Phone Number: (Cell) (Home) I understand that I must have completed 9 th grade by my start date & I must be 15 by August 1. Yes Date of Birth: (Month) (Day) (Year) Gender (circle one): Male / Female Applicant s address (MANDATORY): Person to call in the event of emergency: (Name) (Phone #) (Relationship) Present school attending: Hobbies & Interests: Volunteer experience: Preferred location to volunteer. Please number in order of preference all that may apply (ex. 1 = most desired). Anderson Drake Eastgate Fairfield Liberty Main Campus Mason Northern KY Green Twp

5 Junior Volunteer Commitment As a candidate for the Junior Volunteer Program at Cincinnati Children s Hospital Medical Center: 1. I understand if interviewed and accepted I must complete an online orientation. 2. I will be punctual and conscientious in the fulfillment of my duties. If for any reason I cannot come in at the assigned time I will notify the Volunteer Office. If I am a volunteer at a neighborhood location, I will also notify my direct supervisor. 3. I understand that I am permitted to miss no more than four (4) scheduled volunteer assignments. If I miss more than four (4) times, I understand I will not receive a report of my volunteer hours and I will not be invited to return the following session. 4. I will consider as CONFIDENTIAL all information that I may hear directly or indirectly concerning the patients and their families. 5. I will conduct myself with dignity, courtesy and consideration for others. 6. I will endeavor to make my work of the highest quality. 7. I understand that the Cincinnati Children s Hospital Medical Center maintains a drug free workplace as required by the Drug- Free Workplace Act of I understand that the unlawful manufacture, distribution, sale, possession, or use of controlled substance or illegal drugs by Cincinnati Children s Hospital Medical Center volunteers is prohibited on CCHMC time and in or on Cincinnati Children s Hospital Medical Center s owned or controlled property. 8. I understand that in consideration of patients, CCHMC maintains a smoke-free workplace. While volunteering, my entire person, including clothing, must be free of smoke. 9. I certify that the facts and information provided by me on this application and in my volunteer interview are true and complete. I agree that if accepted as a volunteer, incorrect, incomplete, or falsified information will be grounds for dismissal regardless of when discovered. 10. I agree to observe all Cincinnati Children s Hospital Medical Center s policies and procedures for volunteering at all times. Date Student Signature Date Parent/Guardian Signature **For the parent or guardian of 15 to 17-year-old applicants** I give permission for to serve as a Junior Volunteer at Cincinnati Children s Hospital Medical Center. I have also reviewed the criminal history document and can attest to its truthfulness. Signature: Date: (Parent or Guardian)

6 Personal Essay For your application to be considered, you must complete a personal essay by following the instructions below: TWO FULL PAGES typed double-spaced written in size 12 Times New Roman font NO HEADINGS (Do not leave inches of blank space at the top of the page as a heading) If your essay is not formatted correctly and does not meet the required length of two pages of written content, points will be deducted from the overall score of your application packet. Essay Topic: Please tell us about your previous volunteer experience at Cincinnati Children s Hospital Medical Center and why it is important for you to return this session.

7 CRIMINAL BACKGROUND CHECK DISCLOSURE Cincinnati Children's Hospital Medical Center (CCHMC) is committed to improving child health. As part of our employment screening process, criminal background checks are conducted for all candidates. Criminal background checks promote a safe environment and help protect our patients, families, employees, property and information. Please explain below any felony and/or misdemeanor convictions in Ohio or anywhere else. This includes any offenses to which you plead no contest and those where a judge has made an alternative finding (such as pre-trial diversion, adjudication withheld, or deferred judgment ). Juvenile records, expunged offenses, and sealed records also must be disclosed, and are not an exception in our background check procedure. CCHMC can access all of your conviction history. Note that the only type of offense that you do not have to disclose is a misdemeanor traffic offense (like a parking or speeding ticket) unless your job would involve driving for CCHMC. If you aren t sure or have a question about whether something should be disclosed, you should disclose it. If you have not been convicted of or pleaded guilty to a felony or misdemeanor, please indicate none. CONVICTION DATE OUTCOME In connection with my employment at CCHMC, I authorize background checks of my criminal history. I release CCHMC from all liability resulting from the furnishing of the information. I certify that my disclosures are true and complete to the best of my knowledge. I understand that any false statement or failure to disclose may eliminate me from further consideration for employment or result in termination of employment. Print Name Signature Date Revised February 2014 *** PLEASE ENSURE THAT YOU READ BOTH PAGES OF THIS DISCLOSURE. ***

8 CRIMINAL BACKGROUND CHECK DISCLOSURE The offenses listed below are a partial list of Ohio offenses that will prohibit you from working at Cincinnati Children s Hospital Medical Center. Similar federal or other state offenses also are disqualifying. Certain positions have additional disqualifying offenses. Abduction Aggravated Arson Aggravated Assault Aggravated Burglary Aggravated Menacing Aggravated Murder Aggravated Robbery Aggravated Theft Aiding Escape Arson Assault Assaulting Police Dog Breaking and Entering Burglary Carrying Concealed Weapons Coercion Compelling Prostitution Compounding a Crime Contributing to Unruliness of a Child Corrupting Another with Drugs Criminal Simulation Cruelty to Animals Deception to Obtain a Dangerous Drug Deception to Obtain Matter Harmful to Juveniles Defrauding a Rental Agency Defrauding Creditors Discharge of a Firearm Disclosure of Confidential Information Disrupting Public Services Disseminating Matter Harmful to Juveniles Domestic Violence Endangering Children Engaging in a Pattern of Corrupt Activity Enticement or Solicitation to Patronize a Prostitute; Procurement of a Prostitute for Another Escape Ethnic Intimidation Extortion Failing to Provide for a Functionally Impaired Person Felonious Assault Forging Identification Cards or Selling or Distributing Forged Identification Cards Funding Drug Trafficking Gross Sexual Imposition Having Weapons While Under Disability Human Trafficking Identity Fraud Illegal Administration of a Veterinary Drug Illegal Administration of Distribution of Anabolic Steroids Illegal Assembly or Possession of Chemicals for the Manufacture of Drugs Illegal Conveyance of Weapons or Prohibited Items onto Grounds of Detention Facility or Institution Illegal Conveyance or Possession of Deadly Weapon in Courthouse Illegal Conveyance or Possession of Deadly Weapon in School Safety Zone Illegal Dispensing of Drug Samples Illegal Manufacture of Drugs Illegal Processing of Drug Documents Illegal Use of a Minor In Nudity-Oriented Material or Performance Illegal Use of SNAP or WIC Program Benefits Impersonation of Peace Officer Importuning Improperly Discharging Firearm at or Into Habitation or School Improperly Furnishing Firearms to a Minor Inciting Violence Inducing Panic Insurance Fraud Interference with Custody (would have been Child Stealing if committed prior to 7/1/96) Involuntary Manslaughter Kidnapping Making Terrorist Threat Medicaid Fraud Menacing Menacing by Stalking Misuse of Credit Cards Murder Obstructing Justice Pandering Obscenity Pandering Obscenity Involving a Minor Pandering Sexually Oriented Matter Involving a Minor Participating in a Criminal Gang Passing Bad Checks Patient Abuse or Neglect Patient Endangerment Permitting Child Abuse Permitting Drug Abuse Personating an Officer Placing Harmful Objects in Food or Confection Possession of Drugs Prohibitions Concerning Companion Animals Promoting Prostitution Prostitution; after positive HIV test Public Indecency Rape Receiving Stolen Property Reckless Homicide Riot Robbery Securing Writings by Deception Sexual Battery Sexual Imposition Soliciting Soliciting or Providing Support for Act of Terrorism Tampering with Drugs Tampering with Evidence Tampering with Records Telecommunications Fraud Terrorism Theft Trafficking in Drugs Two or More OVI or OVUAC Violations committed within 3 years immediately preceding the submission of the application Unauthorized Use of a Vehicle Unauthorized Use of Property - computer, cable, or telecommunication property Unlawful Abortion Unlawful Abortion upon a Minor Unlawful Conduct with Respect to Documents Unlawful Display of Law Enforcement Emblem Unlawful Distribution of an Abortion Inducing Drug Unlawful Sale of Pseudoephedrine Product Unlawful Sexual Conduct with a Minor, formerly Corruption of a Minor Voluntary Manslaughter Voyeurism Workers Compensation Fraud Revised February 2014 *** PLEASE ENSURE THAT YOU READ BOTH PAGES OF THIS DISCLOSURE. ***

9 Health Screening Form for Non-CCHMC Personnel Please complete the entire form (including contact information at the top) or we will be unable to accept this form. Name (print): Telephone number: Date of Birth: 1. I have had the following diseases/infections Yes No a. Measles b. Varicella, Chickenpox, Shingles or Zoster (circle those that apply) Year c. Mumps d. Hepatitis B, Hepatitis C, HIV, or other bloodborne pathogens 2. I currently have (or have had in the past year) the following signs or symptoms that might indicate infectious disease that I could transmit in the workplace (circle those that apply and comment on any Yes response) a. Unexplained Fever, night sweats, or weight loss (non-intentional) b. Unexplained Cough of more than 2 weeks duration - with or without bloody secretions c. Unexplained vomiting or diarrhea or bleeding d. Recurrent boils, abscesses, or other skin infection * Comment for Yes responses (diagnosis, any treatment and if ongoing): 3. In the past four weeks, I have been exposed to the following communicable diseases Yes No a. Measles b. Varicella, Chicken Pox, Shingles or Zoster (circle those that apply) c. Pertussis or Whooping Cough d. Diphtheria e. Ebola f. MERS g. Other (please list) * Comment on any Yes response: 4. Tuberculosis Yes No a. I have been vaccinated with BCG. If Yes, when? Year b. Have you spent time with a person known to have active TB or suspected to have TB disease c. I have had a "positive" tuberculin skin test (e.g., PPD) in the past. If Yes, indicate Date: size mm d. I have had active tuberculosis in the past Indicate Date: I have taken anti-tuberculosis medications (e.g., INH) in the past Indicate Date started to e. Date finished f. If Yes to c., d., or e. above, when was your last chest x-ray? Date * Additional comments on any Yes response: 5. Travel Yes No Have you traveled to or had visitors/family members travel to/from the Arabian Peninsula in the past three a. weeks? b. Have you traveled to or had visitors/family members travel to/from West Africa in the past three weeks? c. I will be visiting the US from my home abroad. If Yes, from where? Have you traveled for vacation to a country where Tb disease is common for more than a 2 week period (e.g., Latin America, Caribbean, Africa, India, China, Southeast Asia, Eastern Europe, or Russia)? (circle d. those that apply) When? Have you traveled for business to a country where Tb disease is common for more than a 2 week period? e. (e.g., Latin America, Caribbean, Africa, India, China, Southeast Asia, Eastern Europe, or Russia) Have you traveled for work/service/volunteer to work with those in need in a country where Tb disease is common for more than a 2 week period? (e.g., Latin America, Caribbean, Africa, India, China, Southeast f. Asia, Eastern Europe, or Russia) Work/Volunteer with those in need where TB disease is more common: Homeless shelter, migrant farm g. camp, prison or jail and some nursing homes? (circle those that apply) Have you been associated with persons in a place where Tb disease is more than common such as a h. homeless shelter, migrant farm camp, prison or jail and some nursing homes? Have you had visitors from countries where TB disease is common (most countries in Latin America and the Caribbean, Africa, India, China, Southeast Asia, Eastern Europe, and Russia) living in your home for more i. than 2 weeks? From where?_ By signing below, I acknowledge that I have truthfully answered the questions above. By signing below, I acknowledge that, for the health and safety of Cincinnati Children's Hospital patients, visitors, and personnel, I should not participate in CCHMC activities if I have symptoms of a communicable disease (e.g., fever, cough, or rash illnesses) until those symptoms have resolved. If that condition lasts for > 2 weeks, I should notify Employee Health. Yes No Signature Date

10 CINCINNATI CHILDREN S HOSPITAL MEDICAL CENTER UNIVERSAL VACCINE INFORMATION YES NO Hypersensitive to bakers (bread) yeast? YES NO Acutely ill with fever in past 7 days? Severe life threatening allergic reaction to any vaccines in the past (difficulty breathing, swelling of lips or YES NO throat)? What vaccine? YES NO Is your cardiopulmonary system severely compromised? YES NO Are you pre-dialysis or on dialysis? YES NO Are you the recipient of a solid organ or bone marrow transplant? YES NO Immuno compromised? (current diagnosis or treatment of cancer, leukemia, lymphoma, HIV) YES NO Allergy to aluminum hydroxide, or preservatives 2 phenoxyethanol? YES NO History of severe latex allergy? Or latex sensitivity? YES NO History of Guillian-Barre Syndrome within 6 weeks of receiving a vaccine, history of epilepsy or nervous system diagnosis? YES NO Thrombocytopenia or bleeding disorder? YES NO Allergy to thimerosal other than in contact lense solution? YES NO Allergy to eggs? YES NO Currently pregnant? If yes, what is your due date? YES NO Allergic to neomycin? YES NO Allergic to gelatin? YES NO Taking long term immunosuppressive or steroid therapy or anti malarial agents. YES NO Received blood plasma in the past 5 months? YES NO Received immune globulin or Varicella Zoster immune globulin in the past 5 months? YES NO Previous coma or long seizure within 7 days of your last DTP or DTaP (this was the known cause)? Further explain any yes answers and provide physician documentation: By signing below I acknowledge my responsibility in helping to create a safe environment by being free from Preventable Contagious tuberculosis and other communicable diseases. I understand I should not participate in CCHMC activities if I have symptoms of a communicable disease (fever, cough, rash) until the symptoms have resolved. I also understand that travel outside the United States places me at risk for infectious diseases if not properly immunized prior to leaving the country. I authorize Cincinnati Children s Hospital Medical Center to release my medical record to myself during the dates of my employment. This authorization includes all records to include the use and/or disclosure of information concerning HIV testing or treatment of AIDS or AIDS-related conditions, any drug or alcohol abuse, drug-related conditions, alcoholism, and/or psychiatric/psychological conditions to the above mentioned entity(s). Employee Signature Employee Health Review: Date No action is required, approved for temporary badging. Action required as follows: Signature of Employee Health Nurse Date

Fall 2018 Junior Volunteer Application Packet

Fall 2018 Junior Volunteer Application Packet To be considered for acceptance, the following items on the checklist must be turned in by the deadline (listed on next page): Online portion of application