2018 Student Volunteer Program

Transcription

1 2018 Student Vlunteer Prgram Thank yu fr yur interest in the Student Vlunteer Prgram at Knapp Medical Center. Attached yu will find the applicatin that will assist us in making the best use f yur talents. Requirements fr the Student Vlunteer prgram are few, but they fcus n sharing and cncern fr thers. Yu will find ur Hspital a fascinating place where vlunteers are regarded as an imprtant part f the health care team. The experience yu gain as a Student Vlunteer will benefit yu fr years t cme. Once the cmpleted Applicatin is turned in and reviewed, we will cntact yu t set up a time fr an interview. If yu are accepted, yu will receive a letter fr rientatin. Yu must be at least 15 years f age by June 1, PLEASE READ THE FOLLOWING CAREFULLY: We are ffering yu a great experience and an pprtunity t vlunteer here at Knapp Medical Center. The mrning shift is frm 8:00 a.m. t 12:30 p.m. and the afternn shift is frm 12:30 p.m. t 5 p.m. (If yu cannt attend these shifts, we can make adjustments t yur schedule, but yu will be expected t cme fr yur assigned days.) Please make sure the sessin yu select des nt cnflict with yur daily schl assignments. Minimum hurs are 100 per sessin. In rder fr yu t be cnsidered fr the Prgram, items 1 thrugh 6 listed belw must be received in the ffice in a cmplete packet. Incmplete packets will NOT be prcessed. 1. The cmpleted applicatin 2. The cmpleted Medical Authrizatin Frm. 3. Cpy f Immunizatin Recrd; must include current TDAP vaccine. (Vaccinated within the past 10 years). 4. Current PPD Skin Test 5. Tw letters f recmmendatin frm a cunselr and teacher. 6. The cmpleted Dress Cde Agreement It is ur gal t supprt the hspital departments with cnsistent student vlunteers thrughut the year. We value yur cmmitment t ur hspital staff and depts. It is mandatry that ALL students attend the scheduled rientatin. NO make-ups are available. Students are required t purchase a unifrm pl thrugh Vlunteer Services. The cst f the pl is $ We lk frward t prviding a meaningful and rewarding experience fr yu as part f the Student Vlunteer Prgram at Knapp Medical Center. Please d nt hesitate t call if yu have any questins. Best regards. Imelda Ambriz Manager Vlunteer Services / Gift Shp (956) iambriz@primehealthcare.cm 1

2 Student Vlunteer Applicatin Name: (Last) (First) (Middle) Mailing Address: (City) (Zip Cde) Address: Phne: Birth Date: (Mnth) (Day) (Year) Cell Phne: Grade in Schl: Emergency Cntact: Relatinship: Cntact Number: Department(s) T Vlunteer: Student Acceptance Requirement f 100 Hurs Name f Schl Attending: ACTIVITY LEVEL: Very Active (capable f walking distances and pushing wheelchairs). Mderately Active (sme walking) Limited Activity (requires mstly sitting) Other: Why d yu want t vlunteer? What des Cmpassin r Passinate mean t yu? Hw wuld yu apply it while vlunteering? 2

3 PLEASE READ AND ACKNOWLEDGE: Student: After yur applicatin has been reviewed, yu will be cntacted fr an interview and given an rientatin date. Fllwing satisfactry cmpletin f this training, yu will be given a weekly schedule. A picture will be taken fr an ID badge, and yu will be given a tur f the hspital. Student vlunteers furnish their wn unifrm accrding t the KMC Dress Cde Agreement. (See Attached). Parent/Guardian: I herby give permissn fr my sn/daughter t jin the Student Vlunteer Prgram at Knapp Medical Center, and t vlunteer in whatever area he/she is assigned. I recgnize the respnsibility f the rganizatin and will wrk with my child t cmply with hspital regulatins, which include prviding my sn/daughter with transprtatin and seeing that he/she faithfully fulfills the scheduled assignment f 100 hurs. If Accepted: I agree t abide by the rules and regulatins f the Vlunteer Services Department f KMC. Signature f Student Vlunteer (Date) Signature f Parent r Guardian (Date) Please check size f Pl Shirt needed: Men: S M L XL 2X Wmen: S M L XL 2X PLEASE RETURN COMPLETED PACKET TO: KMC Vlunteer Services Attn: Imelda Ambriz, Manager Vlunteer Services / Gift Shp PO Bx 1110 Weslac, TX Vlunteer Services Use Only: Date applicatin received: Verified by: Check fr cmpletin Applicatin with signatures Tw Recmmendatin letters Medical Authrizatin Frm Dress Cde Agreement with signatures Cpy f Immunizatin Recrd Accepted Declined 3

4 Student Vlunteer Medical Authrizatin Frm T the parent/guardian: The fllwing is needed in case yur child becmes ill r is injured n duty in the hspital as a Student Vlunteer. This infrmatin will be held in the strictest cnfidence. I,, parent/guardian f give authrizatin fr basic first aid and/r emergency medical attentin t be administered at Knapp Medical Center. I authrize the fllwing persns t be cntacted in the event f illness r an accident while my child is n duty as a Student Vlunteer. 1. Name Cntact Numbers 2. Name Cntact Numbers Please give us any additinal infrmatin we might need t knw in case f an emergency (i.e. allergies, medicatins, etc.): **All Charges Related T The Medical Care Of Yur Child Will Be Yur Respnsibility Name: Date: Signature f Parent/Guardian 4

5 KMC Student Vlunteer Dress Agreement A neat, prfessinal appearance is an imprtant part f ur wrking envirnment. Knapp Medical Center and Knapp Medical Center Vlunteer Services have a Dress Cde. Student Vlunteer will wear a unifrm cnsisting f a vlunteer pl, khaki pants, and shes with clsed tes, heels and nn-skid sles. It is mandatry that yu wear yur badge at all times. Pl: Purple pl with KMC Vlunteer lg (purchased thrugh Vlunteer Services). Pl must be tucked in whenever yu vlunteer. Pants: Shes: Full length Khaki pants Unacceptable: Baggy pants, capri pants, shrts, any type f denim stretch pants, leggings and any pants that are nt khaki clr. Belt, if wrn, shuld be brwn r black leather. Shes must have clsed tes, heels, and nn-skid sles. Flat heels nly. Tennis shes are apprpriate and scks are required. KMC Identificatin Badge: Yur KMC Identificatin Badge shuld be wrn n the right side f yur pl cllar at all times. It is mandatry. IF YOU DO NOT HAVE YOUR NAME BADGE, YOU WILL BE SENT HOME. Lst badges will be replaced at a cst f $15.00 Jewelry/Hair Accessries: Ear studs are permissable, but n dangling earrings. Additinal earrings and/r extreme piercing (fr example; eyebrw ring, nse ring, tngue ring and lip rings) are NOT acceptable. Gentlemen may NOT wear earrings. NO Caps are allwed at anytime during yur vlunteering schedule. Ladies must keep lng hair tidy in an apprpriate pny tail r bun. Persnal Hygiene/Makeup: Persnal hygiene is a must Fingernails must be kept clean and be f an apprpriate length. Black nail plish is NOT permitted and/r acyrlic nails. Bright clred hair dye is nt allwed (i.e. green, red, blue, purple, etc.) Makeup shuld be in gd taste. Perfumes and aftershaves shuld nt be wrn while n duty. Nte: Any ther deviatin frm the student unifrm that is deemed inapprpriate by a supervisr will be brught t the Student s attentin and addressed as needed. Vlunteer Services expects every student vlunteer t cmply with this plicy everytime they cme t Knapp Medical Center t vlunteer. Failure t cmply with any part f this plicy will result in immediate terminatin and the Student vlunteer will be drpped frm the prgram. We have read and understand the student vlunteer dress cde plicy. Student Vlunteer Applicant Date Parent r Guardian Date 5

6 Student Vlunteer TB Screening and Skin Testing Recrd Name: DOB: Student Vlunteer #: Department: Vlunteer Services Date: A Tuberculin skin test (PPD) is required fr all emplyees. New emplyees will need the tw-step TB testing if n dcumented prf f annual testing r PPD dne within the last 6 mnths. The first PPD will be given during the hire prcess prir t rientatin and the secnd PPD will be scheduled within tw weeks frm 1 st PPD. PPD testing /TB screening is due annually (January r July). The emplyee MUST return t Emplyee Health fr the PPD reading hurs pst administratin f test. (After hurs / weekends PPD must be read by the Nursing Supervisr.) Signs & Symptms f Tuberculsis (please circle as applies t yur health in previus 6 12 mnths) Lss f weight withut trying r dieting in the last 6 mnths? Yes / N Lss f appetite? If yes, hw lng? Yes / N Persistent night sweats? If yes, hw lng? Yes / N D yu have a frequent persistent cugh? If yes, hw lng? Yes / N Feeling f weakness / fatigue? If yes, hw lng? Yes / N Shrtness f breath? If yes, hw lng? Yes / N Cughing up bld? If yes, hw lng? Yes / N Persistent lw grade fever? If yes, hw lng? Yes / N Swllen glands in neck r ther areas f bdy? Where? Yes / N Medical Histry Histry f psitive TB skin test r bld test? If yes, what year? Yes / N Have yu ever taken medicatin t prevent r treat TB? (INH r Rifampin)Yes / N Have yu ever had a BCG vaccine? If yes, what year? Yes / N Immun-cmprmised r taking medicatins which will suppress the immune system?yes / N Travel Histry: Have yu traveled utside the cuntry in the last 6 12 mnths? Yes / N Authrizatin / Declinatin f Tuberculin Skin Testing I cnsent t the Tuberculin Skin Test and understand I must return within hurs t have it read. I decline the Tuberculin Skin Test due t Previus Psitive, Chest x-ray Allergic Reactin gt elsewhere (Prf) I understand the signs and symptms f TB disease, the need fr TB testing and have had the pprtunity t ask questins. I understand that I must prvide prf f a psitive PPD histry r PPD allergy. I understand that it is my respnsibility t meet the TB/CXR testing requirements and failure t cmply will result in suspensin and / r terminatin. Signature: Date: Tuberculin Skin Testing: (Tuberculin PPD-Aplisl Manufactured by PAR, 0.1 ml Intradermal) NEW HIRE 2 nd Step Annual PPD Repeat PPD:Annual Screening (CXR)Pst-expsure: Baseline / Fllw Date: Time: Site: Right / Left Frearm Lt # Exp. Date: Given By: Date Read: Results: mm Negative/ Psitive Read By: Actin Taken: Educatinal Material prvided Referred t primary physician / Cunty Clinic Chest X-ray Dne: If PPD read by Huse Supervisr, return frm t Emplyee Health drp bx. 6 TB Screening and PPD Recrd frm: EH-TB revised 8/17 mg

7 PARENT PERMISSION FORM Emergency Treatment In the event that I cannt be cntacted, I permit emergency persnnel t take whatever measures are necessary t treat my child fr minr emergencies. Date Signature f Parent r Legal Guardian Emergency Phne Number Immunizatin Infrmatin The Texas Department f Health recmmends that thse brn since January 1, 1957, have tw dses f the measles vaccine (MMR) since 12 mnths f age. The tw dses f measles vaccine must be at least 30 days apart. Befre Student Vlunteers are allwed t vlunteer in the hspital, the frm belw must be signed by parents r guardians verifying that the student has been immunized prperly fr measles. Fr Student Vlunteers unable t verify prper immunizatin, arrangements may be made fr a measles bster t be administered by the Knapp Emplyee Health Nurse. We need t knw if a measles bster is needed. If yu have additinal questins r cncerns, please feel free t cntact yur family physician. I certify that my sn/daughter has been prperly immunized fr measles (MMR) accrding t the Texas Department f Health guidelines stated abve. (At least tw dses f the measles vaccine since age 12 mnths). Immunizatin dates: I understand that despite the exercise f due care, there is a pssibility that my sn r daughter may cntract measles and that Knapp Medical Center neither accepts liability nr respnsibility shuld this ccur. Tuberculsis (Tb) Test Date f Last Tuberculsis Test (TB): Knapp requires annual TB testing. I understand he r she may be required t have a current TB Skin Test administered by Knapp Medical Center. Signature (Parent/Legal Guardian) Date (Please make sure a cpy f yur Immunizatin recrd is attached.) OSHA Categries Of Expsure The Occupatinal Safety and Health Administratin (OSHA) f the Department f Labr published a jint advisry ntice with the Department f Health and Human Services entitled The Prtectin Against Occupatinal Expsure T Hepatitis B (Hbv) And Human Immundeficiency Virus (HIV), 52 Federal Register 41818, Octber 30, 1987, 7

8 t educate health care emplyees t applicable guidelines fr prtectin against these and ther bldbrne pathgens. OSHA mandates that ALL jb psitins and tasks that wrkers are expected t encunter be classified accrding the relative degree f risk f HBV and HIV infectin. The categries are listed belw. Yur present jb categry is: CATEGORY I - Jbs with tasks that rutinely invlve expsure r ptential expsure t bld, bdy fluids, r tissues. All prcedures r ther jb related tasks that invlve an inherent ptential fr mucus membrane r skin cntact with bld, bdy fluids, r tissues, r a ptential fr spills r splashes f these fluids are Categry I Tasks. Use f prtective measures shall be required fr every emplyee in this categry. CATEGORY II Jbs with tasks that d nt rutinely invlve expsure t bld, bdy fluids, r tissues, but emplyment may require perfrming unplanned Categry I tasks. The nrmal wrk rutine invlves n expsure t bld, bdy fluids, r tissues, but expsure r ptential expsure may result during wrk. Apprpriate prtective measures shall be readily available t every emplyee engaged in Categry II tasks. X CATEGORY III - Jbs with tasks that d nt rutinely invlve expsure t bld, bdy fluids, r tissues, and Categry I tasks are nt a cnditin f emplyment. The nrmal wrk rutine invlves n expsure t bld, bdy fluids, r tissues. Persns wh perfrm these duties are nt called upn as part f their emplyment t perfrm r assist in emergency care r first aid r t be ptentially expsed in sme ther way. Tasks that invlve handling f implements r utensils, use f public r shared bathrm facilities r telephnes and persnal cntacts, such as handshaking are Categry III tasks. Student Vlunteer Name: (please print) Signature: DEPARTMENT NAME: Vlunteer Services Infectin Cntrl Nurse: DATE: U:/Nursing/Emplyee Health/Frms/sha categries f expsure.dc{wrd] R 01/17 8