JERSEY SHORE UNIVERSITY 1945 State Route 33 Neptune, NJ 07754 732-776-4177 OCEAN MEDICAL CENTER 425 Jack Martin Blvd. Brick, NJ 08724 732-840-3373 RIVERVIEW 1 Riverview Plaza Red Bank, NJ 07701 732-530-2253 SOUTHERN OCEAN 1140 Route 72 Manahawkin, NJ 08050 609-978-3833 BAYSHORE COMMUNITY HOSPITAL 727 N. Beers Street Holmdel, NJ 07733 732-739-5900 Professional excellence with personal concern We are a smoke-free environment. APPLICATION FOR VOLUNTEER 81746-001cX (7-13) Welcome! We appreciate your interest in meridian health (mh). mh is an integrated health system comprised of acute-care facilities, a regional tertiary-care facility, long term care residences, physician practices and home care agencies. at meridian, we seek talented and compassionate individuals interested in providing quality service, demonstrating professional excellence and achieving a high standard of performance. Please complete the application in ink, giving complete answers to the questions which apply to you. PLEASE PRINT Name (LaST) (FIrST) (middle) (area code) home TeLePhoNe No. PreSeNT address apt. No. (area code) cellular TeLePhoNe No. city STaTe ZIP code e-mail address PERSONAL DATA are YoU BeLoW The age of 18? No YeS IF YeS, how old? VoLUNTeer PoSITIoN applying For: emergency department JOB DATA TraNSPorT have YoU BeeN KNoWN BY other NameS? IN case of emergency call Name: ( ) PhoNe: area code relation ShIP: have YoU ever WorKed/VoLUNTeered at any meridian health affiliates: VoLUNTeer? YeS No Food SerVIceS PaTIeNT care GreeTer clerical other any circle days of WeeK available SaT. SUN. mon. TUe. Wed. ThU. FrI. PaId employee? YeS No IF YeS, LocaTIoN: dates: From To department have YoU ever BeeN denied employment/volunteer assignment BY any meridian health FacILITY? YeS No IF YoU answered YeS, PLeaSe explain, INcLUdING FacILITY and date: referred BY (check one): employee VoLUNTeer employee S/VoLUNTeer S FULL Name ShIFT available 8:00 am - 12:00 Pm 12:00 Pm - 4:00 Pm 4:00 Pm - 8:00 Pm EEO / Affirmative Action Statement: mh does not discriminate against any applicant or employee because of race, sex, age, religion, creed, national origin, sexual orientation, disability, veteran status, or any other protected status in accordance with applicable local, state and federal law. Immigration reform and control act requires I-9 forms verifying alien status be completed within three (3) days of employment. employee S mh SITe: SeLF ad WeBSITe other: Page 1
PROVIDE A COMPLETE LIST OF ALL EMPLOYMENT BEGINNING WITH YOUR MOST RECENT JOB (including military service). Use additional pages if necessary. NoTe: IF YoU Were employed UNder another Name, PLeaSe INdIcaTe IT IN The appropriate SPace, To FacILITaTe our checking references Needed To VerIFY QUaLIFIcaTIoNS. company address city and STaTe ZIP code TYPe of BUSINeSS Name YoU USed as employee STarTING TITLe # hrs/wk Name of YoUr SUPerVISor area code TeL. No. LaST TITLe dates: From To month Year month Year describe BrIeFLY TYPe of WorK PerFormed reason For LeaVING (explain) are YoU PreSeNTLY employed (circle one) 1 2 3 4 WeeKS can We contact YoUr PreSeNT employer? (circle one) YeS No company address city and STaTe ZIP code TYPe of BUSINeSS Name YoU USed as employee STarTING TITLe # hrs/wk Name of YoUr SUPerVISor area code TeL. No. LaST TITLe dates: From To month Year month Year describe BrIeFLY TYPe of WorK PerFormed reason For LeaVING (explain) company address city and STaTe ZIP code TYPe of BUSINeSS Name YoU USed as employee STarTING TITLe # hrs/wk Name of YoUr SUPerVISor area code TeL. No. LaST TITLe dates: From To month Year month Year describe BrIeFLY TYPe of WorK PerFormed reason For LeaVING (explain) LIST ADDITIONAL EMPLOYMENT HISTORY: Include Employer Name & Location, Job Held, and Dates of Employment Have you ever volunteered before? No Yes If yes, for what organizations? from to from to from to Page 2
RECORD OF EDUCATION Name of SchooL address course-degree did YoU GradUaTe? No. of YearS YeS No completed high SchooL college (UNderGradUaTe) GradUaTe SchooL other TraINING relevant To The JoB YoU are SeeKING or courses YoU are PreSeNTLY TaKING REGISTRATION: IF registered, certified or PoSSeSS a LIceNSe, complete The FoLLoWING: registration or certification TITLe NUmBer expiration date PLace of ISSUaNce (city or STaTe) registration or certification TITLe NUmBer expiration date PLace of ISSUaNce (city or STaTe) OTHER SKILLS CLERICAL COMPUTER SKILLS MAINTENANCE OTHER SKILLS (List) dictaphone other (list) ms Word carpenter medical Terminology excel electrician Switchboard Powerpoint Painter cashier access Plasterer Shorthand wpm other Plumber Typing wpm refrigeration MILITARY SERVICE BraNch of SerVIce FINaL rank SerVIce NUmBer SerVIce SchooL or SPecIaL experience GaINed IN The military SerVIce related To PoSITIoN applied For did YoU receive anything other ThaN an honorable discharge? Yes No If yes, please explain: are YoU: retired reserves Page 3
BACKGROUND INFORMATION have you ever been disciplined or discharged for theft, unauthorized removal of company property or related offenses? Yes No have you ever been discharged for fighting, assault or related offenses? Yes No have you ever been disciplined or discharged for being under the influence of alcohol or drugs or for possession or use of alcohol or drugs on the job? Yes No have you ever been disciplined or discharged for violating safety rules? Yes No have you ever been disciplined or discharged for insubordination? Yes No have you had any unauthorized absences in the past year? Yes No have you ever been disciplined or discharged for unsatisfactory performance? Yes No other than traffic violations, have you ever been convicted of a crime which has not been annulled or sealed by the court? Yes No If yes, please state the nature of the offense and date of the conviction? (conviction does not automatically exclude you from consideration of employment) Acknowledgement: I understand that this volunteer application and any other MH document are not contracts of employment and that any individual who is hired may voluntarily leave and may be terminated by MH at any time and for any reason. I understand that no employee or representative of mh other than the President, has the authority to enter into an agreement for employment for any specified period of time and recognize that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon. I understand that my employment with mh volunteer placement may be contingent upon the satisfactory completion of a physical examination including a drug and alcohol screen and the receipt of a satisfactory recommendation from former employers and references. I recognize further that I may be required to submit to any additional physical examinations and/or drug alcohol tests as may be required by mh during the course of my volunteering in connection with the fitness for duty guidelines. I understand mh has a number of facilities and recognize that I may be required to work in facilities and on shifts other than that to which I am initially assigned. I certify that the statements made on this application are true and correct, and thereby grant mh permission to verify the information contained herein. I understand that giving false information or the failure to give complete information as requested herein shall constitute grounds among others for rejection of my application or my dismissal in the event of my employment. If I am applying for a position which requires a high school diploma, Ged, undergraduate or graduate degree, license, registration or certification, I understand I will be required to submit the original document(s) and/or transcripts if applicable, before final acceptance to the position. SIGNaTUre date Page 4
JERSEY SHORE UNIVERSITY 1945 State Route 33 Neptune, NJ 07754 732-776-4177 OCEAN MEDICAL CENTER 425 Jack Martin Blvd. Brick, NJ 08724 732-840-3373 RIVERVIEW 1 Riverview Plaza Red Bank, NJ 07701 732-530-2253 SOUTHERN OCEAN 1140 Route 72 Manahawkin, NJ 08050 609-978-3833 BAYSHORE COMMUNITY HOSPITAL 727 N. Beers Street Holmdel, NJ 07733 732-739-5900 department of volunteer ServIceS health questionnaire (print or type all information on the following pages) Volunteer s Name: Address: Street Town Zip Telephone #: Date of Birth: Section I: To be completed by all applicants. (For chicken pox, rubella, rubeola and mumps, please refer to the exposure chart on page 2 to answer the following questions.) Have you ever had varicella (chicken pox)? Yes No Have you ever been exposed to anyone with chicken pox? Yes No Have you ever had a varicella titer (test)? Yes No We require that all volunteers born after December 31, 1956 provide proof of MMR vaccination. Have you ever had the MMR (measles, mumps, and rubella) vaccine? Yes No If so, when? Have you ever had the German measles (rubella)? Yes No Have you ever been exposed to anyone with german measles? Yes No Have you ever had a rubella titer (test)? Yes No Have you ever had measles? Yes No Have you ever been exposed to anyone with measles? Yes No Have you ever had a rubeola titer (test)? Yes No Have you ever had mumps? Have you ever been exposed to anyone with mumps? Yes No Have you ever had a mumps titer (test)? Yes No Section II: To be completed by all applicants. (PPD and Hepatitis B) Have you ever had Hepatitis? Yes No If yes, date and type: Have you ever been exposed to anyone with Hepatitis B? Yes No Have you ever had the Hepatitis B vaccine? Yes No If so, what are the dates of vaccine? Have you ever had the Hepatitis B surface antibody and antigen testing done? Yes No Have you ever had tuberculosis (TB)? Yes No If yes, did you receive treatment? Yes No 81746-005CX (8-13)
If yes, type of treatment and date: Have you ever been exposed to anyone with TB? Yes No If yes, where and when? Were you treated? Yes No If yes, type of treatment and date: Have you ever had a Mantoux (PPD/TB screening) test? Yes No If yes, date: What was the result of your PPD? Negative Positive If positive, have you had a recent chest x-ray? Yes No If yes, what were the results? If positive, please have your physician complete a Symptom Review Sheet. (This is available from the Occupational Health Department.) exposure chart for diseases chicken pox Spending time with person 4-5 days before rash appears until days after rash appears. German measles (rubella) Spending gime with person 7 days before rash appears until 4 days after rash appears. measles (rubeola) Spending time with person 4 days before rash appears until 3 days after rash appears. mumps Spending time with person 6-7 days before swollen glands appear until 9 days after swollen glands appear. tuberculosis (tb) Spending time with a person with tuberculosis. hepatitis B Direct contact with blood or bloody fluid from an individual with know and active Hepatitis B. Volunteer s Name: Section III: To be completed by all applicants. Are you currently under the care of a physician for any medical condition? Yes No If yes, please indicate: Please list any know allergies: Volunteer s Signature Date Section Iv: To be completed and signed by your physician. I have reviewed the health history of the aforementioned volunteer applicant and the following holds true: This individual is free from contagious disease. Yes No This individual is able to perform physical duties to tolerance. Yes No Limitations: Please list any medications that this patient is currently taking: Doctor s Name (please print or type) Address Doctor s Signature Date