Please feel free to contact us at any time. All questions and comments are welcome! Sincerely,

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1 Thank you for your interest in volunteering with Fairview Hospice. Volunteers are an important part of our care team, and we appreciate your willingness to consider sharing your time and talents with us. Attached you will find a volunteer application, criminal background check form, two reference forms, and directions to our office. Please return your completed application and background check form to: th Ave S. Minneapolis, MN Attention: Volunteer Office The reference forms should be given to someone who knows you professionally (co-worker, teacher, volunteer coordinator, clergy, etc.) When we receive your completed application, we will contact you to set up an interview appointment. Volunteer training is offered two ways: group sessions or self-study. Our group sessions are held on weekday afternoons in January, June, and September at our Minneapolis office. Self-study can be completed any time by watching videos on-line. The self-study wraps up with a two hour session at our Minneapolis office. This session is offered the last week of each month. Volunteer training in Princeton is arranged on an individual basis. We ask that our volunteers give an average of 2-4 hours per week, and the scheduling is quite flexible. Requirements include: completing a criminal background check, completing a health screening with two mantoux (TB) tests, and providing two written references. We also ask that our volunteers give at least 50 hours of service (approximately one year) at a minimum. Please feel free to contact us at any time. All questions and comments are welcome! Sincerely, Anne Myers-Richards Erin Goblirsch Volunteer Supervisor Volunteer Specialist amyersr1@fairview.org egoblir1@fairview.org

2 Fairview Hospice Volunteer Application Name of Applicant Date: Street Address City State Zip Home Phone ( ) Work Phone ( ) Cell ( ) Address Birthdate: Month Day (For birthday card list only. Do not list year) Employer Occupation Can you receive calls at work? Yes ( ) No ( ) Emergency Only ( ) Education/Special Training Work Experience Have you served as a volunteer previously? Yes ( ) No ( ) If yes, where? Have you previously volunteered at a Fairview facility? Yes ( ) No ( ) If yes, where? Have you previously been employed at a Fairview facility? Yes ( ) No ( ) If yes, where? Are you 18 years of age or older? Yes ( ) No ( ) Have you ever been convicted of a crime? Yes ( ) No ( ) If yes, enter dates and names of convictions. Applicants are not obligated to disclose sealed or expunged records of conviction or arrest. Identify Areas of Interest: Patient/Family Care ( ) Office Support ( ) Fundraising ( ) How did you hear about the Fairview Hospice volunteer program? Why do you want to be a hospice volunteer? What qualities (skills, talents, knowledge, and experiences) do you feel you can incorporate into your hospice volunteer work? Signature Date

3 MN Department of Human Services Criminal Background Study First Name: Middle: Last Name: Date of Birth: Gender: Male Female MN Driver License #: FIELDS MARKED WITH AN ASTERISK (*) ARE OPTIONAL. *Race: Asian Pacific Islander African American Native American Caucasian Other *Social Security #: *Phone #: Address: City: State: Zip: OTHER FIRST NAMES YOU HAVE USED: First: First: First: OTHER LAST NAMES YOU HAVE USED Last: Last: Last:

4 MINNESOTA DEPARTMENT OF HEALTH LICENSED FACILITIES SUPPLEMENTAL NURSING SERVICES AGENCIES, EDUCATIONAL PROGRAMS, TEMPORARY EMPLOYMENT AGENCIES, PROFESSIONAL SERVICES AGENCIES BACKGROUND STUDY PRIVACY NOTICE Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data Practices Act requires that you be informed of the following: 1. Purpose and intended use of the information: Minnesota Statutes, section , requires the Minnesota Department of Human Services (DHS) to conduct background studies on individuals who have direct contact with patients and residents in hospitals, boarding care homes, outpatient surgical centers, nursing homes, home care agencies, residential care homes, board and lodging establishments registered to provide supportive or health supervision services, individuals employed by supplemental nursing services agencies, and controlling persons of a supplemental nursing services agency; and all other employees in nursing homes. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS. 2. Whether you may refuse or are legally required to provide the information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study. 3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with (and, where applicable, access to) persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified. 4. Known consequences that will arise from refusing to supply the requested information: Only items identified as optional may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact with (and, where applicable, access to) persons receiving services. 5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, the Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The information about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent. 9/03

5 Directions to Fairview Home Care and Hospice The Fairview Home Care and Hospice building is located at th Avenue South a twostory white building on the corner of 26 th Avenue and 25 th Street. Traveling on I-94 going east Take the Riverside/25th exit #235A. Turn right on 25 th Avenue and proceed south for approximately 5 blocks. You will see our office building on the right at the corner of 26 th Ave. and 25 th Street. Traveling on I-94 going west Take the Riverside/25th exit #235A. Turn left on 25 th Avenue proceed south for approximately 5 blocks. You will see our office building on the right at the corner of 26 th Ave. and 25 th Street. Traveling on 35W going south Merge onto Hiawatha Ave/MN-55 E via exit number 17A. Turn Left onto 26 th Street East. Then turn Left onto 26 th Ave S. You will see our office building on the corner of 26 th Ave. and 25 th Street. Traveling on 35W going north Merge onto I-94 E exit #16B. Take exit #235A 25 th Ave/Riverside Ave. Turn right on 25 th Avenue and proceed south for approximately 5 blocks. You will see our office building on the right at the corner of 26 th Ave. and 25 th Street.

6 Volunteer Reference Check The individual named below has applied to become a volunteer at Fairview Hospice and has given your name as a reference. Your evaluation of this applicant would be appreciated. The information you provide will assist us in making appropriate placements and will be considered confidential. Please return this form as soon as possible. Volunteer Applicant 1. In what capacity have you known the applicant and for how long? 2. Please describe the characteristics of the applicant that would make them an appropriate volunteer. Consider maturity, reliability, initiative, willingness to work, interpersonal skills. 3. Describe the applicant s ability to work with different age groups, people with serious medical conditions, and people of diverse cultures. 4. Do you feel the applicant is well organized and can attend to details? Refererr s Name (print) Refererr s Phone #: Signature Date Thank you for completing this form. If you have any questions please contact Anne Myers-Richards, Volunteer Supervisor Mail to: Fairview Hospice Attention: Volunteer Department th Ave S Minneapolis, MN Or FAX to Anne Myers-Richards at

7 Volunteer Reference Check The individual named below has applied to become a volunteer at Fairview Hospice and has given your name as a reference. Your evaluation of this applicant would be appreciated. The information you provide will assist us in making appropriate placements and will be considered confidential. Please return this form as soon as possible. Volunteer Applicant 1. In what capacity have you known the applicant and for how long? 2. Please describe the characteristics of the applicant that would make them an appropriate volunteer. Consider maturity, reliability, initiative, willingness to work, interpersonal skills. 3. Describe the applicant s ability to work with different age groups, people with serious medical conditions, and people of diverse cultures. 4. Do you feel the applicant is well organized and can attend to details? Refererr s Name (print) Refererr s Phone #: Signature Date Thank you for completing this form. If you have any questions please contact Anne Myers-Richards, Volunteer Supervisor Mail to: Fairview Hospice Attention: Volunteer Department th Ave S Minneapolis, MN Or FAX to Anne Myers-Richards at