Download Stony Brook Southampton Hospital Volunteer Application and more Exams Medical Records in PDF only on Docsity!
APPLICATION FOR NODA
COMPASSIONATE COMPANION VOLUNTEERS
Date___________________________
Name________________________________________________________________
Mailing Address _________________________ City_________________ Zip_________
Telephone_______________________ Cell Phone_____________________________
E-mail Address _________________________________________________________
EMERGENCY CONTACT_________________________________________________
REFERENCES: Present Employer ___________________________________________
Address _____________________________ Phone Number__________
SPIRITUAL AFFILIATION ________________________________________________
VOLUNTEERISM:
PREVIOUS VOLUNTEER EXPERIENCE_______________________________________
REASON FOR VOLUNTEERING____________________________________________
ON CALL AVAILABILITY: Days most available__________________________________ (4 HOUR SHIFTS) Times most available _________________________________
Seasonal Volunteer? ____ What Months? _________________
SECOND LANGUAGE___________________________________________________
AS A VOLUNTEER, I WILL:
- Take any problems, criticisms or suggestions to the Director of Volunteer Services
- Endeavor to make my work professional in its quality.
- Uphold the traditions and high standards of this Hospital and will interpret them to the community at large.
- Be punctual and conscientious in the fulfillment of my duties and accept supervision.
- Uphold the volunteer dress code as established by the Volunteer department.
- Conduct oneself with dignity, courtesy and consideration.
- I understand that the Volunteer department reserves the right to terminate my volunteer status as a result of (a) failure to comply with Hospital policies, rules and regulations; (b) absences without prior notification; (c) unsatisfactory attitude, work or appearance; or (d) any other circumstances which, in the judgment of the department director, would make my continued service as a volunteer contrary to the best interests of the Hospital.
STONY BROOK SOUTHAMPTON HOSPITAL VOLUNTEER SERVICE CONFIDENTIALITY STATEMENT
Volunteers have access to a wide variety of confidential information regarding a patient, the Hospital, its Medical Staff and employees. Under no condition can this information be disclosed. All patient care information is to be regarded as confidential. Access to medical records is limited to our medical staff and any other person the patient may allow. Information obtained by any volunteer in the course of his/her service is strictly confidential, and the volunteer shall not divulge such information to any person either orally or in writing. Failure to comply with the Hospital policy on confidentially may be grounds for dismissal.
Volunteer Signature Date
FOR OFFICE USE ONLY:
Interview Date_____________________ Orientation Date_________________________
Starting Date ______________________ Assignment _____________________________
Days_____________________________Times__________________________________
Comments_______________________________________________________________
_______________________________________________________________________
________________________________________________________________________
Date_____________________________Interviewer______________________________
Applicant Name: ________________________________________ Date of Birth: _____________________
Health Assessment Information for Volunteer Applicants
The following documentation from your private physician is needed to satisfy the health requirements for volunteering. Please be sure to carefully read each item listed below.
- Two MMR (Measles, Mumps, Rubella) Vaccines documented as follows: Dates Administered Signed and Stamped by Doctor OR Positive Titers: Documented on a Lab report including Lab values for: Mumps – IGG Rubella (German Measles) – IGG Rubeola (Measles) – IGG
- Negative PPD (dated within 3 months – 2 step PPD is required) documented as follows: Date planted Result Date read Signature, Stamp and License Number by an M.D., P.A., or N.P. OR QuantiFERON Gold (a type of blood test that is used to diagnose tuberculosis). Negative result documented on a lab report. OR If you have had a past positive PPD, a negative chest x-ray report is required.
- Influenza Vaccination (Seasonal Flu Vaccine) All volunteers must receive a seasonal influenza vaccine OR unvaccinated volunteers MUST wear a surgical mask at all times while in areas where patients may be present during the period the NYS Commissioner of Health determines the influenza season is underway.
- Two Varicella Vaccines documented as follows: Dates Administered Signature, Stamp and License Number by an M.D., P.A., or N.P. OR Positive Titers: Documented on a Lab report including Lab values OR If you do not wish to obtain the varicella vaccine you MUST sign the varicella vaccine declination statement below
Varicella Declination I understand that varicella is a potentially serious, vaccine-preventable disease and that I may be at risk of acquiring and transmitting the disease. I have been offered the varicella series, but choose to decline at this time. If at any time I choose to receive the varicella vaccine series as an active hospital volunteer, I may do so at no charge to me.
Signature of applicant Date
If you do not have a positive titer or documentation of two doses of the MMR vaccine and/or the Varicella Vaccine, the vaccinations are available at no cost at Employee Health Services. Volunteer Services will schedule an appointment for you when you submit your application.
240 Meeting House Lane
Southampton, NY 11968
Phone (631) 726- 8376 Fax (631)726- 8344
EMPLOYEE HEALTH PHYSICAL EXAMINATION FORM To be completed by health care practitioner
Name_____________________________ Date of Birth ____________Position Title____________________
Age________ Ht_________ Wt_________ Temp_________ Pulse_________Resp_________ BP ____/_____
Vision: Rt 20/_____ Lt 20/_____ [ ] Glasses [ ] Without [ ] With [ ] Reading [ ] Distance
Ishihara's Color Test [ ] Normal [ ] Abnormal Administered by: __________________Date_______
Medications: ______________________________________________________________________________
Allergies: _________________________________________________________________________________
Physical Examination
WNL Abnormal Comments General Appearance Abdomen Back/Spine Extremities Lungs Heart HEENT Neurological Skin
Recommendations:
Can employee perform essential functions of position? ___________________________________________
Describe any limitations and/or accommodations that may required: _______________________________
Refer to PMD for medical clearance related to:_________________________________________________
Comments/Questions:______________________________________________________________________
Print Practitioner’s Name: _____________________________________________
Practitioner's Signature______________________________________________Date___________________ Meeting House Lane Medical-(631) 283- 2100 Fax to Employee Health- (631)726- 8344 __________________________________________________________________________________________
