JAMES A. HALEY VETERANS’ HOSPITAL, VOLUNTARY SERVICE 13000 Bruce B. Downs Boulevard, Tampa, FL 33612 (Building 1, Room 2A-215L)

Phone: 813-972-7533 E-Mail: VHATAMVoluntaryService@va.gov

Revised 02/06/2020

VISION: Promote a positive experience for youth volunteers with an opportunity for personal and professional growth while benefitting the VA hospital, the Veteran-patients, and staff.

MISSION: We strive to offer varied, meaningful experiences, with systematic supervision by subject matter experts to provide students with a foundation for volunteerism within the VA, tools for successful engagement as developing community leaders, and an understanding of opportunities for future federal employment.

YOUTH VOLUNTEER BASICS

Youth Volunteers must be between the ages of 14-17 years old by June 1, 2020

Youth Volunteer positions are limited! Not all applicants may be accepted for the program.

Applications will be reviewed and scored based on: GPA, extracurricular activities, teacher recommendations, and a writing sample.

SCHEDULE AND HOURS: o Youth Volunteers must commit to a minimum of 100 hours for the duration of the program:

June 3 – July 24, 2020. Youth may earn up to 200 hours during the period! o Youth will receive an individual assignment schedule and volunteer four (4) to eight (8) hours each day. o Volunteering will take place daily, Monday – Thursday during the work week.

(There are no Friday, weekend, or evening opportunities, except for the final Friday ceremony.) o Four (4) absences will be allowed before removal from the program. o All assignments are located at the main Tampa Campus (13000 Bruce B. Downs Blvd.)

Accepted applicants must be able to attend the scheduled orientation, all scheduled volunteer dates, and adhere to volunteer guidelines.

Please look at your personal calendar to decide if this is a good fit for you!

Complete ALL Application Checklist Items

Applications must be received in to the Voluntary Service Office NO LATER THAN APRIL 24, 2020 at 3:00 PM. Incomplete applications or applications lacking required signatures will not be considered.

Only hard copy applications will be considered (no emailed or faxed applications)

Selected applicants will receive Notification of Acceptance by MAY 15, 2020.

Due to the volume of applicants, exceptions will NOT be made to the above criteria.

Summer Schedule

Assignment Rotation 1 OFF: June 29 – July 3

Assignment Rotation 2

Orientation: Week 1:

June 8 – June 12

Week 2: June 15 – June 19

Week 3: June 22 – June 26

Week 4: July 6 – July 10

Week 5: July 13 – July 17

Week 6: July 20 – July 24

Monday Wednesday, June 3

Orientation (6 hours)

4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours Tuesday 4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours

Wednesday 4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours Thursday 4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours

Friday OFF OFF OFF OFF OFF OFF Ceremony

2020 JAHVH Summer Youth Volunteer Application

JAMES A. HALEY VETERANS’ HOSPITAL, VOLUNTARY SERVICE 13000 Bruce B. Downs Boulevard, Tampa, FL 33612 (Building 1, Room 2A-215L)

Phone: 813-972-7533 E-Mail: VHATAMVoluntaryService@va.gov

Revised 02/06/2020

Application Checklist for:

YOUTH LAST NAME

YOUTH FIRST NAME

1. Application Checklist (1 page)

2. Application for Voluntary Service (2 pages)

3. Agreement Form for Parents / Guardians and Students (1 page)

4. Questionnaire for Youth Volunteers (1 page)

5. Writing Sample (1 page)

6. Hospital Guidelines (1 page)

7. Consent for production and use of verbal or written statements or photographs (2 page)

8. Minor/Youth Volunteer: Medical History and Tuberculosis Test Authorization (1 page)

9. School Transcript

10. Are all of the mandatory forms complete with signatures?

Incomplete applications will not be considered

Voluntary Service Office Use Only

Date Received:

Time Received:

Staff Initials:

DATE

OMB Number 2900-0090 Estimated Average: 15 min.

APPLICATION FOR VOLUNTARY SERVICE The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 15 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. The form is used to assist personnel of both voluntary organizations, which recruit volunteers from their membership, and the VA in the selection, screening and placement of volunteers in the nationwide VA Voluntary Service program. The volunteer program supplements the medical care and treatment of Veteran patients in all VA facilities. PRIVACY ACT INFORMATION: The information requested on this form is solicited under the authority of 38 U.S.C. 7405(a)(1)(D) and will be used in the selection and placement of potential volunteers in the VA Voluntary Service Program. The information you supply may be disclosed outside VA as permitted by law; possible disclosures include those described in the 'routine uses' identified in the VA system of records 57VA135 Voluntary Service Records-VA, published in the Federal Register in accordance with the Privacy Act of 1974. The routine uses include disclosures: in response to court subpoenas, to report apparent law violations to other Federal, State or local agencies charged with law enforcement responsibilities, to service organizations, employers and Unemployment Compensation Offices to confirm volunteer service, and to congressional offices at the request of the volunteer. Disclosure of the information is voluntary, however, failure to furnish the information will hamper our ability to arrange the most satisfactory assignment for you and the Department of Veterans Affairs.

NAME (Last, First, Middle Initial)

1.

RESTRICTIONS, LIMITATIONS OF SERVICE (Health Concerns, Medications, Allergies, etc.) AVAILABILITY (Days and Times)

IN CASE OF EMERGENCY, PLEASE CONTACT (Name, Relationship, Phone Number)

Monetary Waiver: I hereby waive all claims to monetary benefits for services rendered as a volunteer worker on a "without compensation basis" for an indefinite period. I understand that this waiver applies only to remuneration (compensation) for specific services rendered in the VA Voluntary Service (VAVS) Program and is not related to any other VA services or benefits to which I may be entitled. (NOTE: VA has entered into this agreement by the authority of 38 U.S.C. 7405(a)(1)(D). This agreement may be canceled by either party upon written notice.) I hereby accept the volunteer appointment(s) as outlined above.

Volunteer Signature Date

OFFICE USE ONLY

1. SUPERVISOR 2. SUPERVISOR PHONE NUMBER

3. ORIENTATIONS 4. UNIFORM

VA FORM FEB 2016 10-7055 EXISTING STOCK OF VA FORM 10-7055, MAY 2007, WILL BE USED.

I hereby appoint this applicant as a VA without-compensation employee subject to the provisions on this application. The above individual has been provided basic and assignment specific orientations which have been documented in the official volunteer folder located in the VA Voluntary Service Office.

VAVS Program Manager - Appointing Official Signature Date

EXPERIENCE AND TRAINING (Special Skills/Abilities)

TELEPHONE NUMBER E-MAIL ADDRESS

ORGANIZATION MEMBERSHIP(S) (Unit, Post, Chapter, if Affiliated)

ADDRESS (Street, City, State and Zip Code) DATE

DATE OF BIRTH

ASSIGNMENT PREFERENCES SEX M F

2. 3.

Summer youth must attend all scheduled days from June 3 - July 24, 2020

Summer youth assignments will be given during orientation on June 3, 2020

James A. Haley Veterans’ Hospital (Parent / Guardian Signature)

NOTE TO STUDENTS AND PARENTS/GUARDIANS: The VA medical center is a federal building, and, as such, must be open to the public. Our employees, patients, and volunteers come from diverse backgrounds. Eligible Veterans are entitled to services offered by VA, even if they have had problematic incidents in their past - unless the law specifically disqualifies them. Our job is to provide care to Veterans and to protect our employees, patients, and volunteers as that care is provided.

STUDENT VOLUNTEER: If accepted, I agree to adhere to the policies and procedures of this VA healthcare facility and to respect the confidentiality of information pertaining to the patients and their treatment. If a patient, staff member, volunteer, and/or visitor is abusive, makes inappropriate gestures, advances, or conversation, that is in a manner which makes me feel uncomfortable, I will immediately inform my supervisor or a VAVS staff member.

YOUTH SIGNATURE DATE

PARENT/GUARDIAN: The above-named student has my consent as parent/guardian to serve as a Student Volunteer in this VA healthcare system. I have read the above agreement as signed by my student and understand their obligation to the program if they are accepted into the VAVS Student Volunteer Program. I also grant permission for my child to receive emergency medical treatment if injured while volunteering.

PARENT/GUARDIAN SIGNATURE DATE

NOTE: Completion of this application does not guarantee acceptance into this program.

JAHVH Summer Youth Volunteer Program Agreement Form for Parents / Guardians and Students

YOUTH LAST NAME

YOUTH FIRST NAME

1. Commitment of Service AgreementAs a Summer Youth Volunteer, I commit to completing the entire Summer Youth Program:

Assignment Rotation 1 OFF: June 29 – July 3

Assignment Rotation 2

Orientation: Week 1:

June 8 – June 12

Week 2: June 15 – June 19

Week 3: June 22 – June 26

Week 4: July 6 – July 10

Week 5: July 13 – July 17

Week 6: July 20 – July 24

Monday Wednesday, June 3

Orientation (6 hours)

4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours Tuesday 4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours

Wednesday 4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours Thursday 4 – 8 hours 4 – 8 hours 4 – 8 hours OFF 4 – 8 hours 4 – 8 hours 4 – 8 hours

Friday OFF OFF OFF OFF OFF OFF Ceremony - I understand that I will be placed in two (2) assignments over the course of the summer.- I understand that I should volunteer no more than eight (8) hours per day.- Voluntary Service Staff is NOT responsible for the well-being of youth-volunteers outside of their

assigned areas or when the volunteer is not engaged in the scheduled assignment.- I understand that after four (4) absences, I will be removed from the Voluntary Service Summer

Youth Program

2. Dress CodeAs a Summer Youth Volunteer, I recognize the VA hospital is a professional environment and agree to wear the dress code every day that I volunteer at JAHVH. I understand that if I arrive at the hospital out of dress code my parent or guardian will be notified and I will be sent home.

Long pants (jeans or khakis) No shorts, no skirts

Close-toed shoes (absolutely no flip-flops orsandals)

Volunteer badgeSelect size of shirt (adult sizes):

☐Small ☐Medium ☐Large ☐XL ☐2XL ☐Other_______

3. Occupational/Employee Health FormsI, ________________________________ (parent or guardian of youth volunteer) understand that if the Minor/Youth Volunteer: Medical history and Tuberculosis Test Authorization form is not completed in its entirety, the application for the youth volunteer will not be considered.

YOUTH Signature: Date:

PARENT / GUARDIAN Signature: Date: Print PARENT / GUARDIAN Name: PARENT / GUARDIAN Phone Number: Alt. Phone:

JAHVH Summer Youth Volunteer Program QUESTIONNAIRE FOR YOUTH VOLUNTEERS

YOUTH LAST NAME

YOUTH FIRST NAME

If referred by a Veteran Service Organization, please list it here: (e.g. Veterans of Foreign Wars, Salvation Army, American Red Cross, American Legion Auxiliary, etc.)

1. What grade are you starting Fall 2020?

2. What is your current (unweighted) GPA? Attach your most current transcript.

3. What extra-curricular or community activities have you been involved within the pastyear? (List activities and how you participated.)

4. Provide the contact information (including e-mail) of two teachers within the pastschool year for references. (this must be the school/work e-mail, not a personal e-mail)

Teacher’s Name

School/Work e-mail

Teacher’s Name

School/Work e-mail

5. Does your Parent / Guardian work at James A. Haley Veterans’ Hospital?(If so, we want to make sure youth are not placed in the same areas.)

No. Yes. If so, please print their name and work area:

Community Service, Internships, Shadowing Voluntary Service does NOT oversee internships, students seeking academic credit,

individuals seeking to observe/shadow medical personnel, or community service requirements.

JAHVH Summer Youth Volunteer Program WRITING SAMPLE

YOUTH LAST NAME

YOUTH FIRST NAME

In the space below, provide a typed writing sample explaining: - Your reason for volunteering at JAHVH;- What you believe to be the impact of volunteering: personally, for the organization, and for Veterans; and- What you hope to learn from the experience.

The writing sample should not exceed 250 words and will be rated on content, spelling, and grammar. You may attach a separate page if necessary.

JAMES A. HALEY VETERANS’ HOSPITAL, VOLUNTARY SERVICE 13000 Bruce B. Downs Boulevard, Tampa, FL 33612 (Phone: 813-972-7533 Fax: 813-903-4865)

S:\Voluntary\Applications\Youth\Individual files for edit\Hospital Guidelines - JAHVH.docx Rev 2019-09-06

Hospital Guidelines for Volunteers It is your RIGHT and RESPONSIBILITY:

To have a tuberculosis screening prior to beginning your assignment

To respect confidences of JAHVA and those receiving care and services.

To be punctual and regular in your assignment. Every volunteer has a VA staff supervisor.

To perform only those duties to which you have been assigned by your supervisor. Performing “jobs” that are not assigned is NOT volunteering.

To report any unusual behavior to the police or your supervisor.

To be a good listener, friendly but impersonal, but not probe or ask overly personal questions. Conduct yourself with dignity and courtesy at all times.

To report for your assignment well-groomed and attired in clothing appropriate to a hospital setting, being mindful of good personal hygiene.

To NOT become financially involved with a patient. You cannot handle banking needs nor involve yourself with safe deposit arrangements. Do not sign wills, legal documents or business papers of any kind. Do not lend money or borrow from anybody.

To NOT give your address or phone number to anybody. If necessary, you can be reached through the Voluntary Service Office.

To NOT take gifts, alcohol, food, beverages or medicine to a patient unless instructed to do so by a VA doctor, nurse or your supervisor.

To never to make suggestions to patients about treatments or remedies or discuss or argue conversational topics such as race, religion or politics

To not photograph, film, video or audio tape any patient without prior written authorization.

To not allow yourself to become emotionally involved with patients. You MUST NOT show any partiality.

To be assigned a job that is worthwhile and challenging, with freedom to use existing skills or develop new ones.

To be kept informed through newsletters, e-mail, telephone contacts, and special events about what is going on at JAHVA.

To receive orientation, training, and supervision for the assignment you accept and to know why you are asked to do a particular job. Also, to accept and respect any advice or suggestions from the staff; we are here to help you.

To expect that your time will not be wasted by lack of planning, coordination, and cooperation within the facility.

To know whether your work is effective and how it can be improved; to have a chance to increase your understanding of yourself, others, and your community.

To ask for a new assignment within the hospital.

To accept an assignment of your choice with only as much responsibility as you can handle.

To decline work not acceptable to you; not let biases interfere with job performance; not proselytize or pressure others to accept your standards.

To continue only as long as you can be useful to the organization in supporting the need and mission.

To refuse gifts or tips and direct any potential donations to the Voluntary Service Office.

To understand that all volunteer / group / organizational activities must be coordinated through Voluntary Service.

To use reasonable judgement in making decisions when there appears to be no policy or the policy has not been communicated to you. Then, as soon as possible, consult with your supervisor for future guidance.

To provide feedback, suggestions, and recommendations to your supervisor and Voluntary Service staff in ways that may increase the effectiveness of the program.

To be considerate, respect competencies, and work as a member of a team with all staff and other volunteers.

To be proud of volunteering at James A. Haley Veterans’ Hospital.

I HAVE READ AND UNDERSTAND THE ABOVE HOSPITAL GUIDELINES. I ALSO UNDERSTAND THAT ANY VIOLATION OF THESE RULES IS GROUNDS FOR IMMEDIATE DISMISSAL.

SIGNATURE OF VOLUNTEER DATE

VA FORM 10-3203NOV 2014

NOTE: The execution of this form does not authorize production or use of materials except as specified below. The specified material may be produced and used by VA for authorized purposes identified below, such as education of VA personnel, research activities, or promotional efforts. It may also be disclosed outside VA as permitted by law and as noted below. If the material is part of a VA system of records, it may be disclosed outside VA as stated in the “Routine Uses” in the "VA Privacy Act Systems of Records" published in the Federal Register.

The purpose of this form is to document your consent to the Department of Veterans Affairs' (VA) request to obtain, produce, and/or use a verbal or written statement or a photograph, digital image, and/or video or audio recording containing your likeness or voice. By signing this form, you are authorizing the production or use only as specified below.

You are NOT REQUIRED TO CONSENT TO VA's REQUEST to obtain, produce, and/or use your statement, likeness, or voice. Your decision to consent or refuse will not affect your access to any present or future VA benefits for which you are eligible.

You may rescind your consent at any time prior to or during production of a photograph, digital image, or video or audio recording, or before or during your provision of a verbal or written statement. You may rescind your consent after production is complete if the burden on VA of complying with that request is not unreasonable considering the financial and administrative costs, the ease of compliance, and the number of parties involved.

CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS, PHOTOGRAPHS, DIGITAL IMAGES, AND/OR VIDEO OR AUDIO RECORDINGS BY VA

The photograph, digital image, and/or video or audio recording will be produced while I am (describe the activity or situation) (To Be Completed by the Department of Veteran Affairs, if applicable)

Name of individual whose statement, likeness, or voice is requested

I hereby voluntarily and without compensation authorize

Check at least one of the following (to be completed by VA)

Name of Facility

to produce a photograph, digital image, and/or video or audio recording of me (or of the above named individual if the individual is legally unable to give consent).

to obtain or use a verbal or written statement from me ( or the of the above named individual if the individual is legally unable to give consent).

Name of Facility I hereby voluntarily and without compensation authorize

Name of individual whose statement, likeness, or voice is requested

a youth volunteer at James A. Haley Veterans' Hospital. This may include any time I am functioning within my assignments or otherwise involved with Voluntary Service.

James A. Haley Veterans' Hospital

James A. Haley Veterans' Hospital

First Name Last Name

VA FORM 10-3203NOV 2014

PAGE 2

I consent to allowing VA to record and use a verbal or written statement, or produce and use photographs, digital images, and video or audio recording for the purpose(s) identified below:

This product will be used: (NOTE: At least one of these boxes must be checked as well as a purpose described below) (to be completed by VA)

Internally (stay within VA) Externally ( shared outside VA)

Please check the applicable purpose(s) (to be completed by VA)

Promotional Efforts:

Internal Publication (only VA) External publication (publicly available)

Other (Specify):

Other (Specify):

ConferencePresentation

Research Activities: Study

Education Purposes:

Publication in a Journal Training

Other (Specify):

Performance Improvement

VA ONLY Use:

Quality Improvement Health Care Operations

All of the Above

NOTE: Do not sign this form unless one or more of the boxes above has been checked.

I have read and understand the foregoing, and I consent to the use of a verbal or written statement from me, and/or of my likeness and/or voice as specified for the above-described purpose(s). I understand that no royalty, fee, or other compensation of any kind will be made to me by the United States for such use. I understand that consent to obtain, produce, and/or use a verbal or written statement, photograph, digital image, and video or audio recording containing my likeness or voice is voluntary, and my refusal will not adversely affect my access to any present or future VA benefits for which I am eligible. I further understand that I may, at any time, rescind my consent prior to or during production of a photograph, digital image, or video or audio recording. I also understand that I may rescind my consent after production is complete if the burden on VA of complying with that request is not unreasonable considering the financial and administrative costs, the ease of compliance, and the number of parties involved.

Print Full Name (First and Last Name) Signature Date

Print Employee Full Name Title Date

Signature

Consent Obtained By (TO BE COMPLETED BY VA)

Signature of Person Obtaining Consent (TO BE COMPLETED BY VA)

IMPORTANT: If VA is providing or releasing any patient health or demographic information with the verbal or written statement, photograph, digital image, or video or audio recording, VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information, is required prior to the release of such data to any source outside VA.

Print Full Name (First and Last Name) Signature Date

VOLUNTARY SERVICE SPECIALIST

MINOR/YOUTH VOLUNTEER: MEDICAL HISTORY and TUBERCULOSIS TEST AUTHORIZATION

Parent/Guardian Authorization YOUTH VOLUNTEER INFORMATION

-- -- YOUTH VOLUNTEER NAME (LAST, FIRST) FULL SOCIAL SECURITY NUMBER

FEMALE MALE STREET ADDRESS

/ / CITY, STATE & ZIP CODE DATE OF BIRTH (MM / DD / YYYY)

PARENT/GUARDIAN INFORMATION & EMERGENCY CONTACT

PARENT/GUARDIAN NAME RELATIONSHIP TO YOUTH

STREET ADDRESS CITY, STATE, ZIP CODE

PHONE (PRIMARY) PHONE (ALTERNATE)

ALTERNATE CONTACT NAME RELATIONSHIP TO YOUTH

PHONE (PRIMARY) PHONE (ALTERNATE)

FAMILY DOCTOR (NAME) FAMILY DOCTOR (PHONE)

I, ________________________________________________________________, THE PARENT / LEGAL GUARDIAN of the above youth hereby give permission that the youth may receive a Tuberculosis (Tb) Quantiferon lab test (Tuberculosis screening lab test). I further give permission for my son/daughter to be evaluated for any incident that is related to a volunteer job injury or illness. Note: If the youth has had a positive Tuberculin Skin Test (TST), please provide if available a Tb Quantiferon Gold lab result. If the Tb Quantiferon lab test was determined positive, an updated Chest X-ray (CXR) report within the past 12 months will need to be submitted. If the youth has not had a Chest X-ray (following a positive Quantiferon lab test) within 12 months, he/she will need to be referred to his/her primary care provider to obtain an updated CXR and provide both the Quantiferon lab test and CXR result attached to this form. Tb tests (blood draw) will be given at no charge during the student orientation.

-Does the youth haveallergies? NO. YES. If yes, list:

-Does the youth take anymedication? NO. YES. If yes, list

-Does the youth have anylatex sensitivities? NO. YES. If yes, explain

-Has the youth ever receiveda BCG inoculation? NO. YES (This is a common vaccination that they might have

received as a child if born in a foreign country.) -Does the youth have any medical conditions that weaken the immune system? (Examples of factors that might weaken theimmune system include: HIV infection, diabetes, severe kidney disease, organ transplants, cancer, medical treatments such ascorticosteroids, chemotherapy, specialized treatment for rheumatoid arthritis or Chron’s disease.) NO. YES. If yes, explain:

Has this child ever had a tuberculosis (TB) skin test or blood test which was positive? NO. YES Was a chest X-ray done? NO. YES If so, was it positive? NO. YES

Please indicate if the youth has received these immunizations:

Tetanus Diphtheria & Pertussis (Tdap) NO. YES Varicella (Chicken Pox) Illness or Vaccine NO. YES

Measles/Mumps/Rubella NO. YES Hepatitis B Vaccine NO. YES

PARENT/GUARDIAN SIGNATURE DATE