VOLUNTEER APPLICATION FORM THANK YOU FOR YOUR INTEREST IN BECOMING A HOSPICE VOLUNTEER, THIS INFORMATION HAS PROVEN TO BE MOST HELPFUL IN MAKING OUR VOLUNTEER ASSIGNMENTS. PLEASE PRINT PERSONAL NAME LAST FIRST MIDDLE BIRTH MONTH DATE EMAIL CITY STATE ZIP PHONE EMERGENCY CONTACT PHONE EMPLOYMENT HISTORY CURRENT EMPLOYMENT STATUS NOT EMPLOYED FULL TIME PART TIME SELF EMPLOYED OCCUPATION EMPLOYER EMPLOYER CITY STATE ZIP PHONE VOLUNTEER HISTORY DESCRIBE VOLUNTEER ACTIVITIES AND TYPE OF WORK PERFORMED: Have you experienced a death of a close friend or relative in the past 13 months? NO YES If yes, please explain:
EDUCATION SCHOOL ATTENDED CITY STATE ZIP SCHOOL ATTENDED CITY STATE ZIP INTERESTS AND SKILLS INTERESTS AND SKILLS THIS A SAMPLE LIST OF SERVICES PROVIDED BY VOLUNTEERS. PLEASE CHECK THOSE SERVICES YOU ARE WILLING TO PROVIDE: CARE GIVER RELIEF (RESPITE) BEREAVEMENT SPIRITUAL CARE OUTDOOR CHORES (YARD WORK, SNOW REMOVAL) COMPANIONSHIP VISITS CLERICAL TASKS(TYPING WORD PROCESSING, MAILINGS, ETC) LIFE STORY PET THERAPY PROGRAM SUPPORT VOLUNTEERS ASSIST HOSPICE IN SEVERAL WAYS. YOUR COMMITMENT TO ANY OF THE FOLLOWING AREAS WOULD BE GREATLY APPRECIATED. PRESENTER FOR VOLUNTEER TRAINING SPEAKERS BUREAU SPECIAL EVENTS NEWSLETTERS FUND RAISING PLEASE LIST SPECIAL HOBBIES, SKILLS OR INTERESTS YOU MIGHT BE INTERESTED IN SHARING (I.E., SINGING, STAMP COLLECTING, READING, FISHING,ETC.) AVAILABLE TIME FOR VOLUNTEER WORK DAYS EVENINGS WEEKENDS HOW MUCH TIME CAN YOU GIVE FOR VOLUNTEER SERVICE HRS PER WK DO YOU HAVE RELIABLE SELF TRANSPORTATION? YES NO HOW DID YOU HEAR ABOUT OUR VOLUNTEER PROGRAM? REFERENCES - PLEASE LIST 2 PLEASE GIVE THE NAMES OF 2 PEOPLE, NOT RELATED TO YOU, THAT WE MAY CONTACT FOR A PERSONAL REFERENCE. PLEASE INCLUDE, PHONE, FULL STREET, ALONG WITH CITY, STATE AND ZIP. NAME NAME PHONE PHONE CITY, ZIP CITY, ZIP RELATIONSHIP TO YOU RELATIONSHIP TO YOU SIGNATURE DATE
PRE-PLACEMENT SCREENING QUESTIONAIRE Health questionnaires are completed pre-placement Job offer for employment in accordance with ADA NAME-LAST, FIRST LAST NAME MI AGE POSITION APPLIED FOR DATE TELEPHONE ( ) FAMILY PHYSICIAN FIRST NAME SEX TELEPHONE ( ) Home Healthcare, as a provider of Healthcare, has a responsibility to positively assist employees in their health status. Therefore, we are asking you to fill out the questionnaire below which will be reviewed by our clinical manager or designee prior to placement with a Client. Should there be an indication that you are unable to perform an essential function of the position, with or without an accommodation, or that your performing the function would be injurious to yourself or the health of the client, the branch will request a follow-up examination by a qualified physician. Have you had and/or do you have problems with any of the following: Have you had and/or do you have problems with any of the following: Vision Hearing Speech No Yes If yes, please explain: No Yes If yes, please explain: Mental illness Phobias Other Smell Have you had and or/do you have problems with any of the following: Chest Pain No Yes If yes, please explain: Problem breathing Dizziness Seizures Loss of consciousness, fainting Balance Tremors, shaking Hernia (Rupture) Varicose veins Allergies Rashes, skin problems Tuberculosis Arthritis/ joint pain Paralysis Lifting Carrying Grasping Reaching Bending Twisting Sitting Climbing stairs Standing for prolonged periods Walking Pushing/pulling Squatting Kneeling Driving DO YOU TAKE ANY MEDICATIONS THAT MAY AFFECT YOUR PERFORMANCE OF THE ESSENTIAL FUNCTIONS OF THE JOB? NO IF YES, PLEASE LIST: YES HAVE YOU PREVIOUSLY RECEIVED THE HEPATITIS B VACCINATION SERIES? NO YES IF YES, WHEN: WHERE: IS THE HEPATITIS B VACCINATION CONTRAINDICATED FOR YOU? NO YES IF YES, WHY: EMPLOYEE (APPLICANT) SIGNATURE DIRECTOR/CLINICAL MANAGER/DESIGNEE SIGNATURE DATE DATE REVIEWED
VOLUNTEER IDENTIFICATION AND RELEASE REGARDING INVESTIGATION OF CRIMINAL HISTORY A. IDENTIFICATION: (Please Print-Clearly) Name: Last First Middle Alias, Maiden, Previous Married Name Current Address ZIP CODE - PLEASE INCLUDE COUNTY Previous Address ZIP CODE - PLEASE INCLUDE COUNTY Current Phone# Current Cell Phone # Home Email Address B. Disclosure 1. Have you ever been convicted of any crime other than a minor traffic violation? YES NO 2. If yes, give the offense, the date convicted, and the name and location of the court which convicted you. Updated 03-09-2009
(MI residents only:) Have you worked in Long Term Care prior to April 1, 2006? Yes No Date of Birth: Place of Birth: (City/County/State/Country) Eye Color: Sex: Male Female Citizenship: This space left blank Hair Color: Height: Weight: Drivers License #: Social Security #: Race (optional): C. AUTHORIZATION AND RELEASE The undersigned acknowledges: 1. That he/she has executed this document in conjunction with an application for volunteering with Trinity Home Health Services; 2. That he/she hereby authorizes Trinity Home Health Services access to any criminal history record produced by federal, state or local law agencies pertaining to the undersigned; 3. That he/she agrees to release Trinity Home Health Services and any other person, company or other entity from any and all causes of action that otherwise might arise from supplying Trinity Home Health Services with information it may request pursuant to this release; 4. That he/she understands that Public Act 28 a health care facility, home care/hospice agency or an agency that is a nursing home, county medical facility or home for the aged, conduct criminal background checks on prospective employees and volunteers. These health care facilities would be prohibited from employing, independently contracting with, or granting clinical privileges to an individual who has direct access to patients and residents if the individual has been convicted of certain offenses. These offenses include but are not limited to various felony and misdemeanor convictions. 5. That he/she understands that any false answers or statements, or misrepresentations by omission made by him/her on this form or any related document, will be sufficient cause for rejection of his/her application or for his/her immediate discharge should such falsifications or misrepresentations be discovered after his/her commencement of services. Volunteer Signature Date Updated 03-09-2009
THE NEXT TWO SHEETS ARE FOR PERSONAL REFERENCES. PLEASE ASK TWO PEOPLE TO FILL THEM OUT AND RETURN WITH YOUR APPLICATION. NO FAMILY MEMEBERS PLEASE. IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO CONTACT ME. LOOKING FORWARD TO WORKING WITH YOU, KAREN D. CAHILL VOLUNTEER COORDINATOR SAINT AGNES HOSPICE 6729 N. WILLOW AVE., #103 FRESNO, CA 93710 (559) 450-5623 KAREN.CAHILL@SAMC.COM
Reference Check Questions Name of Reference: Name of Potential Volunteer: How long have you known the applicant? How do you know him/her (as a friend, employer, co-worker, etc.)? What are some personal qualities that this person will bring to the volunteer experience of Hospice? Would you say that this individual is dependable? Do you feel this individual could emotionally handle patient care for terminally ill people? Do you feel that this individual has any unresolved grief issues that would impede him/her at the patient s bedside? Respondent's/Referee's signature Date
Reference Check Questions Name of Reference: Name of Potential Volunteer: How long have you known the applicant? How do you know him/her (as a friend, employer, co-worker, etc.)? What are some personal qualities that this person will bring to the volunteer experience of Hospice? Would you say that this individual is dependable? Do you feel this individual could emotionally handle patient care for terminally ill people? Do you feel that this individual has any unresolved grief issues that would impede him/her at the patient s bedside? Respondent's/Referee's signature Date
Saint Agnes Hospice Volunteer Interview Volunteer Name: Date: 1. What motivated you to apply for a volunteer position with Saint Agnes Hospice? 2. Do you know what the hospice philosophy is? 3. What do you think your role and responsibilities will be? 4. What other volunteering have you done? 5. What do you regard as your greatest strengths for this kind of volunteer work? 6. How does your family feel about you volunteering for hospice? 7. Have you experienced a significant loss (death, divorce, job loss) within the last 13 months? We ask you wait 13 months before volunteering after a death of a family member or close friend to allow for the grieving process. 8. What was your first experience with death or dying?
9. Hospice works with people with cancer, Aids, dementia as well as other non-cancer diagnosis. How would you feel about being with someone who has serious physical limitations or altered appearance resulting from their illness or treatment? 10. How do you feel about working with patients and their families of different races, religion, economic or spiritual backgrounds? 11. Volunteers provide emotional and practical support for people who are living with and dying from a terminal illness. Is there anything that might be difficult for you? Because volunteer training is a major commitment of time and effort for you and Saint Agnes Hospice, do you anticipate anything that might interfere with fulfilling a one year commitment? Do you have any questions or concerns? Interview Conduct By: Date: Karen Cahill Volunteer Coordinator