Dear Volunteer Applicant,

Transcription

1 Dear Volunteer Applicant, Thank you for your interest in volunteer opportunities at North Shore-LIJ Southside Hospital. Southside Hospital is regionally recognized for its specialized services including cardiac surgery, brain injury, medical rehabilitation, psychiatry, level II perinatal service, area trauma center and stroke care designations, medical/surgical services, and pediatrics. The hospital has been recognized as a New York State Department of Health Designated Stroke Center. The advent of the Cardiac Surgery program completed Southside Hospital s comprehensive continuum of diagnostic and interventional cardiac services and the hospital now has an Accredited Community Hospital Cancer Program, as designated by the American College of Surgeons Commission on Cancer, as well. Based on its traditions of excellence and caring, Southside Hospital demonstrates respect for human beings as whole persons, promoting health in body, mind and spirit. By offering a personal and compassionate approach to healthcare delivery through volunteering at our hospital, you will become part of a very special group that is committed to our caring philosophy. I hope that you join us and reap the satisfaction and pride through volunteer service. When you volunteer, you will also enjoy free parking and a complimentary meal voucher when you volunteer. Please review the enclosed material about our volunteer program. If you are interested in joining our team, please complete and return the application to my office. Our goal is to match your talent and time to one of our many opportunities. By giving just a few hours of your time a week, you can truly make a difference. Sincerely, Patricia McColley Manager, Volunteer Service Department NSLIJ- Southside Hospital 301 East Main Street Bay Shore, NY Tel:(631)

2

3 North Shore-Long Island Jewish Health System Pre-Placement Health Assessment The New York State Department of Health (DOH) and/or North Shore LIJ Health System mandates that all persons seeking employment and/or an appointment to the Medical Staff of a hospital in the North Shore-Long Island Jewish Health System have a current physical and recorded medical history as well as documented immunity as outlined in our infection control policy. To insure your safety and the safety of our patients, all of the following requirements must be completed prior to employment or providing services. For your convenience, you can elect to have many of your exams and tests performed by either your personal physician or North Shore-LIJ Employee Health Services (EHS). Requirements include: 1. Physical examination (within last 12 months) 2. Tuberculosis Screening - this may be satisfied by either of the approved tests to detect M. tuberculosis infection: Blood based Tuberculosis Screen Tests, approved FDA test are: o QuantiFERON-TB Gold o QuantiFERON-TB Gold In-Tube o TSpot.TB OR Two-step Tuberculin Skin Testing (TST/PPD) o Provide documentation to EHS of two negative TSTs performed within the past 12 months. The 2nd TST must be within the past 3 months. OR Positive TST History o Documentation of positive TST result o A standard chest x-ray report done within the past 12 month 3. Immunizations: submit either copies of laboratory titers or proof of vaccination Rubeola (Measles) Mumps Rubella Tetanus/Diphtheria or Tetanus/Diphtheria/Pertussis Hepatitis B surface antigen and surface antibody results Varicella Vaccination documentation should include the signature of the person who administered the vaccine as well as the product and date administered 4. Urine Toxicology Screening 5. Color Vision Testing (as clinically required) 6. Respiratory Questionnaire and Fit Testing (as clinically required) 7. Latex Allergy and Sensitivity Screening If you have arranged an appointment at EHS, please complete these forms prior to your appointment and bring them with you.

4

5

6

7 North Shore-Long Island Jewish Health System Screening for Allergies/ Sensitivities to Latex Products First Name: Last Name: DOB : / / Dept/Div: Title/Position Today s Date: / / Work Phone Number: ( ) - ext. 1. Do you have a history of Latex Allergy reactions?...yes No 2. Are you allergic or sensitive to foods containing...yes No bananas, avocados or chestnuts? 3. Do you develop itching, wheezing or a rash from the use of:...yes No rubber gloves or rubber bands or blowing up balloons? 4. Have you ever tested positive for a latex skin or blood test?...yes No 5. Have you ever had a prior unexplained allergic or anaphylactic reaction...yes No during a medical procedure (also known as a system reaction? latex_screening_form_ doc

8 North Shore-Long Island Jewish Health System Southside Hospital APPLICATION FOR VOLUNTEER SERVICE NS-LIJ is an Equal Opportunity Employer and a Voluntary Not-for-Profit Health System Please print in INK I am over 18 years of age I am between the ages of 14 & 18 Mr. Mrs. Ms. Last Name: First Name: Mid. Int: Today s Date: Social Security # Date of Birth: Spouse Name (if applicable) Home Address: (Street) (City/Town) (State) (Zip) Phone: Home: ( ) Phone: Business: ( ) How did you hear about the NSLIJHS Volunteer Program? Emergency contact: Foreign Language spoken: (Name) (Phone#) (Relationship) Do you have any friends or relatives employed, volunteering, or on the Board of Trustees at the NS-LIJ Health System? Yes No if yes, please provide information: Facility Department Name Relationship Did you previously work or volunteer? Yes No If Yes, please specify: (Hospital/Facility) (Dept.) (Date(s) I am currently: Employed Unemployed Retired Homemaker Student Employer s Name (if applicable): (Name) (Address) Education: High School College/Univ. Degree Business/Trade School presently attending: Major: What is your reason for volunteering? I prefer: Patient contact Non-patient contact Clerical Where needed Application for Volunteer Services 4/17/2013

9