Dear Prospective Volunteer, Thank you for your interest in volunteering at your community hospital! One of the requirements for becoming a Fairview Ridges Hospital volunteer is to attend a hospital orientation that will acquaint you with the hospital setting and the Junior Volunteer Program. Orientations will be held in the hospital s conference rooms A & B on: Monday, June 27, 2011 Monday, August 1, 2011 Monday, September 19, 2011 For your convenience, an Employee Health nurse will be available before the orientation (5 to 6 pm) to perform health screenings and give Mantoux (TB) tests. A parent or guardian needs to be present during this assessment and can leave once the orientation begins. You also need to bring the following: - Proof of your immunizations with dates (2 MMR s and chicken pox). Please bring a copy for us to keep. If you are not able to attend or complete the screening on the orientation date, please call Employee Occupational Health Services 612-672-5050 to schedule a health assessment appointment at Fairview Ridges Hospital. Please fill out and return the bottom portion of this letter to Volunteer Services for orientation registration. If you have questions, please contact me at (952) 892-2193. See you at orientation! Sincerely yours, Mona Wagner, Manager Volunteer Services --------------------------------------------------------------------------------------------------------------------------------------------------- JUNIOR VOLUNTEER ORIENTATION REGISTRATION Space is limited, so respond quickly! Please PRINT! I will attend the following orientation: Monday, June 27, 2011 Monday, August 1, 2011 Monday, September 19, 2011 I will be there at 5 pm to complete my Health Screening. A parent or guardian will attend with me and I will bring my signed health assessment form and proof of immunizations. Name: Phone: formsjunior Volunteer Orientation Letter _3-29-10.doc
PLEASE JUNIOR VOLUNTEER APPLICATION Fairview Ridges Hospital 201 East Nicollet Boulevard Burnsville, MN 55337 Volunteer Services 952-892-2035 PRINT OR TYPE FULL LEGAL NAME Today s date: Name: (Last) (First) (Middle) Age: Date of Birth: Phone: Address: City State Zip E-mail address Education: FOR OFFICE USE Application received Initial Contact Ack Interview By Health Review Assign Schedule Start Date Comments: Grade in school Name of school Employment: Current Employer: Position: List work hours and days: Additional Information: To what school, church, or community organizations do you belong? List current or previous volunteer experience: Skills, interests, hobbies: Do you speak a foreign language? Sign language? (specify) Please list names of any volunteers you may know here.
How did you learn of the Fairview Ridges Junior Volunteer Program? Do you have any health problems that we should be aware of? No Yes (specify) Availability for volunteering: Morning Preferred day (s) Afternoon Evening Weekend Please specify what volunteer area (s) interest you: Prior to acceptance into the volunteer program, every applicant is required to complete a brief health history with Health Services. You may be required to take a mantoux test for TB and show proof of immunization history. Fairview Ridges is committed to the policy that all persons shall have equal treatment and opportunity in every aspect of our relationship with staff and volunteers without regard to race, color, religion, sex, national origin, age, marital status or physical handicap (except when based on a bonafide occupational qualification). Date Signature of applicant Please list names of any volunteers you may know here.
Please have your parent complete the form below. My daughter / son has my consent to serve as a volunteer at Fairview Ridges Hospital. Parent signature Date In the event that my daughter / son should require medical attention while on duty as a volunteer, I understand that Fairview Ridges Hospital will first make every attempt to contact me through the emergency numbers listed below. Emergency contacts: Name Relationship Phone (H) (W) Name Relationship Phone (H) (W) If unable to make contact with anyone at the designated emergency numbers, I give my permission to Fairview Ridges Hospital to administer medical care/treatment to my son / daughter should he / she require medical services while on duty as a junior volunteer. Parent signature Date: WPDocs/JuniorFiles/JuniorVolunteerApplication
Reference for Junior Volunteer DATE APPLICANT ADDRESS PHONE SCHOOL TEACHER This student has applied to be a Junior Volunteer at Fairview Ridges Hospital. It will help us to evaluate this student s abilities and suitability for this kind of volunteer work if you will answer the following questions. According to your records and knowledge, please comment on the following traits: Attendance at school / punctuality Ability to learn / initiative Ability to follow through Ability to work with others Ability to prioritize and multi-task Respectful communication with others Additional comments TEACHER S SIGNATURE PHONE PARENTS: State and Federal legislation requires that schools must have parental consent to release information regarding students. Please sign this form and have your son or daughter turn it in to a teacher or school counselor. My daughter or son has my consent to serve as a volunteer at Fairview Ridges Hospital. Guardian Signature Teachers : RETURN REFERENCE FORM TO: Fairview Ridges Hospital/ Volunteer Services 201 East Nicollet Boulevard Burnsville, MN 55337 Jr ref. for application.doc
FAIRVIEW HEALTH SERVICES VOLUNTEER HEALTH ASSESSMENT All new Fairview Health Services Volunteers will be screened for their immunization status and will be given appropriate tuberculosis testing by a Fairview Employee Occupational Health Nurse prior to training. Please call the Employee Occupational Health Service Center (EOHS) at 612-672-5050 to schedule an appointment for a Volunteer Health Assessment. Please read the following information that explains the requirements for immunity and tuberculosis testing. Bring a copy of your immunization records with you to the Health Assessment appointment. Immunization records may be obtained from your schools, medical clinics or health departments. Titers or blood test results indicating immunity are also acceptable. IMMUNIZATIONS Rubella (German Measles), Rubeola (Red Measles) and Mumps The following are considered acceptable proof of immunity to these diseases: Documentation of 2 live virus vaccines with the first being on or after 12 months of age, Documentation of history or diagnosis of by any health care provider or Documentation of positive titer. Varicella (Chicken Pox) The following are considered acceptable proof of immunity to varicella: Documentation of 2 vaccines, or Documentation of positive titer or Documentation of history or diagnosis of varicella by any health care provider. If there is a questionable history, a titer will be ordered by the nurse. If the result indicates you are not immune to german measles, red measles or mumps Employee Health will provide you the required vaccination. A written record of the chicken pox immunization from the health care provider s office must be provided to Employee Occupational Health Services. Volunteers who are not immune to chicken pox will be restricted from working with newborns or neonates and immunosuppressed or immunocompromised patients. TUBERCULOSIS SKIN TESTING (MANTOUX) The 2-Step Tuberculin Skin Test (TST), otherwise known as a Mantoux, is administered to assess if you have ever been exposed to tuberculosis. It is a skin test given by a nurse on the inner aspect of the forearm. The first TST will be done at pre-placement evaluation. You must return to Employee Occupational Health Services with your Tuberculosis Screening Form in 48 to 72 hours to have the test read and documented on your form. The second TST will be administered 1 week after the first. You will not be cleared to work as a volunteer until the Mantoux test is read. A positive result (a red bump on the skin) may mean that you Q:\Sou th west -Shares \FSH\ShareDir \C ommunication s and Mark eting \Juli e H en n en Mikkelson \Ju li e's folder\frh\volunteerhealthassess2008.doc Page 1 of 2 Revised August 2008
were exposed to tuberculosis at sometime during your life but doesn t necessarily mean you have tuberculosis. If your test is positive, the Employee Occupational Health Services will order a chest x-ray. If you have a history of a previous positive Mantoux test you will not be given another test. In this situation you will be given a short questionnaire to answer. If you have had a chest x-ray done within the last 12 months you will be asked to supply a copy of the chest x- ray report. If you have not had a chest x-ray report within the last 12 months Employee Occupational Health Services will order a chest x-ray. You will not be cleared to work as a volunteer until the results of the chest x-ray are available. PHYSICAL RESTRICTIONS If you have any physical restrictions that would affect your ability to volunteer please bring a note from your health care provider explaining these restrictions. This information will be helpful to make an appropriate volunteer assignment. JUNIOR VOLUNTEERS Junior volunteers will need to have a parent or legal guardian sign a consent form for administration of the Mantoux test or immunizations or to have titers drawn. Junior Volunteer s Name: Date of Birth: Social Security Number: Acceptance Into Fairview Health Services Volunteer Program I give my permission for my child to have TB Testing (Mantoux), and/or titers as needed for compliance with infection control immunization policy, and to be seen for first aid treatment by Employee Occupational Health Services if needed. I understand Employee Occupational Health Services will notify me of a positive test results for Mantoux s and abnormal titers. I understand that I may revoke this consent at anytime and upon fulfillment of the above stated purpose, this consent will automatically expire without my express revocation twelve (12) months from the date of signature. I do not authorize further release to any third party. Signature: Relationship: Date: (Parent/Guardian signature required for volunteers less than 18 years of age) These health policies have been developed by Fairview Employee Occupational Health Services in cooperation with Fairview Volunteer Services to protect the health and safety of volunteers, employees, visitors and patients. THANK YOU FOR VOLUNTEERING FOR FAIRVIEW! Q:\Southwest-Shares\FSH\ShareDir\Communications and Marketing\Julie Hennen Mikkelson\Julie's folder\frh\volunteerhealthassess2008.doc Page 2 of 2 Revised August 2008