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The University of Iowa Hospitals and Clinics Volunteer Application

General Information Date: ___________________

Legal Name: (Last) (First) (Middle)

Local Street Address:

City:

State: Zip:

Primary Phone:

Email address:

Are you a college student? High school student?

If yes, expected year of graduation:

Date of birth: University of Iowa ID:

Social Security Number:

Gender: Male_______ Female _______ Prefer not to say _______

Family members employed at UIHC (please list names, relationship to you, departments):

Employment HistoryAre you currently employed?: Yes ______ No _____

Please describe past and present employment positions, dating back five years. Attach anadditional sheet if necessary. Please account for all periods of unemployment.

Name of employer:

Length of employment (include dates):

Position & duties:

Reason for leaving:

Volunteer Experience Please list previous and current volunteer experiences:

Is your volunteer work a requirement for school credit? Is your volunteer work for assigned community service hours? If yes, please explain:

How did you become interested in Volunteer Services at our hospital?If you were referred to us, please indicate who referred you:

If you came to this orientation with assignment preferences, what are they? What are your skills/interests?

School attending:

(if applicable)

(If you do not have a Social Security Number, please inform a member of the staff when you drop off your application)

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Health and Emergency Information Do you have any physical limitations that would limit your volunteer experience? If so, please specify: Emergency Contact:

Relationship to you:

Home phone:

Work phone:

References (Please no relatives or personal physicians. Professsional references preferred.)

1. Name Address/City/State Phone Relationship to you

2.

Name Address/City/State Phone Relationship to you 3.

Name Address/City/State Phone Relationship to you

Background Information The University of Iowa Hospitals and Clinics must be able to assure the safety of all patients in their care. Therefore, we ask you to provide us with the following information which will remain in the strictest confidence, which means that we shall use our best efforts to ensure that the following information will not be released other than to comply with a court order, subpoena, or as otherwise required by law. Otherwise such information will only be used to determine your suitability for placement. The existence of a criminal conviction history is considered only to the extent that it relates to a particular volunteer position.

• Have you ever been convicted for violation of any municipal, county, state or federal law other than a minor parking violation? Yes: _____ No: _____

• Have you ever been reported for child abuse and/or neglect to the Department of Human Services or a similar agency in any state? Yes: _____ No: _____

• Have you ever been terminated, suspended or placed on probation, or otherwise penalized for abuse or maltreatment of any person? Yes: _____ No: _____

If you answered yes to any of these questions, please provide date(s), description(s) and an explanation of incident(s):

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Declarations and Volunteer Agreement

As a hospital volunteer, I understand Volunteer Services reserves the right to terminate any 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 Volunteer Services Director, would make my continued services as a volunteer contrary to the best interests of the hospital. In addition:

• I certify that the statements made in this volunteer application are true and correct and have been given voluntarily. Any falsification or significant omission of information may result in my rejection or dismissal from participation in Volunteer Services at the University of Iowa Hospitals and Clinics.

Signature:

Printed Name:

Date:

E-Mail Address:

People with disabilities are welcome at UI Hospitals and Clinics. The University of Iowa prohibits discrimination in employment or in its educational programs and activities on the basis of race, national origin, color, creed, religion, sex, age, disability, veteran status, sexual orientation, gender identity or associational preference.

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Short Essay In the space below, please type/write a short essay answering the following questions: What do you want to gain from volunteering? What will make you a successful, dependable volunteer? In answering your question, please use no smaller than 12 point font.

Volunteer Services

200 Hawkins Drive, 8025 JCP Iowa City, Iowa, 52242-1009

319-356-2515 Tel319-384-8032 Fax

www.uihealthcare.org

Letter of Volunteer Intent

I understand that to become a volunteer at UI Hospitals and Clinics, a commitment to volunteering three hours per week for two semesters is required for college student volunteers and six consecutive months for community volunteers. This equates to over 72 total hours.

Considerable hospital resources are dedicated to screen, collect background information, health screen, photo ID badge, appropriately orient, assess, train, place and supervise volunteers at the hospital, all of which are provided at no cost to me.

In addition, the dependability of volunteers directly affects the quality of the placements available to me, particularly in areas with direct patient contact.

With this in mind, I have considered my obligations and should I be accepted as a volunteer at UI Hospitals and Clinics, pledge to contribute three hours per week for a minimum of 72 total hours.

Signed:_______________________________ Date: ____________

Notification and Authorization for Release ofInformation for Criminal Background Check

Department NameVolunteer Position TitleNotice: In connection with your application to volunteer at The University of Iowa, a criminal background check will be conducted on you.

Failure to provide consent will deny further consideration of your volunteer application. If the check reveals a criminal conviction, you will beinformed of the record and be given a reasonable opportunity to provide clarifying information. If upon further review, it is The University ofIowa’s judgment that the conviction has a nexus to the volunteer position for which you have applied, you will no longer be underconsideration. You will be informed in writing of such action. If you seek future employment at The University of Iowa, the hiring departmentmay be informed of this action and may be directed to take this information into consideration when evaluating your application and/orappointment.

Authorization: By signing below, you authorize: (a) General Information Services, Inc. (GIS) to request information about you from anypublic information source; (b) anyone to provide information about you to GIS; (c) GIS to provide us (The University of Iowa) one or morereports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your volunteerposition. GIS may investigate your address history, social security number validity, criminal record, driving record, and any other informationwith public information sources. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make thisauthorization to be valid for as long as you are an applicant with us. You understand that my date of birth is used solely as an identifier toavoid possible misidentification while completing the background check process.

The following information is required to identify yourself. Please print clearly.

Volunteer Name (first name, middle name, last name)

Other Names Used Date of Change

Other Names Used Date of Change

Current Street Address

City, State, Zip

List all cities, states, and zip codes you have lived in, if the above does not encompass 7 years

Driver’s License Number State Issued

Social Security Number Date of Birth

Telephone Number

I certify that answers given herein are true and complete to the best of my knowledge. I understand that falsestatements made on this application or incomplete information may eliminate me from further consideration ormay be grounds for dismissal.

SIGNATURE Date– FOR INTERNAL USE ONLY –Background Check Completed (Date)Senior HR Unit Representative (Name)Check revealed conviction? YES NOIf yes, was the conviction determined to have a nexus to the volunteer position? YES NODate adverse action letter sent to volunteer

_______________________________________________________________________________________________________

________________________________________________

Volunteer Services

University of Iowa Hospitals and Clinics Volunteer

Disclosure

The University of Iowa will obtain one or more consumer reports about you for purposes of volunteering. We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is General Information Services, Inc. GIS’s address is P.O. Box 353, Chapin, SC 29036. GIS’s telephone number is (866) 265-4917. GIS’s website is at www.geninfo.com.

To prepare the reports, GIS may investigate your address history, social security number validity, criminal record, driving record, and any other information with public information sources.

You may inspect GIS’s files about you (in person, by mail, or by phone) by providing identification to GIS. If you do, GIS will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification.

If GIS obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed.

Please sign below to acknowledge your receipt of this disclosure.

________________________________________ _________________________________________ Signature Date

________________________________________ Printed Name

Last updated March 2013

Copyright The University of Iowa 2013. All rights reserved.

 

Confidential Volunteer Reference (Professional references preferred. Please no relatives or personal physicians.)

Name of Volunteer Applicant: ___________________________________

To the Reference: The person listed above has applied to be a volunteer at the University of Iowa Hospitals and Clinics.

Volunteers in our program have both direct and indirect contact with patients, and this reference is required in our office

before the applicant is allowed to volunteer. Please complete and place this form in an envelope with your signature

over the seal, and return to the applicant. Applications are not considered complete until we have a reference letter in a

signed and sealed envelope in our office, attached to their volunteer application.

How long have you known the applicant? _____________ years _____________months

What is your relationship to the applicant? ____________________________________________________

Please rank on a scale of 1 to 5, with 1 being the least positive, 5 being the most positive:

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

1 2 3 4 5 No Basis

This person has a high level of initiative

This person has good people skills

This person is able to work independently

This person is dependable

This person is punctual

This person is trustworthy

This person works well with others

This person would be an asset to UIHC

What is their attitude towards supervision?

What are their strengths?

What are their weaknesses?

Any additional comments you would like to add?

Reference Name:______________________________ Phone Number:____________________ (please print name)

Reference signature:__________________________________________ Date:______________

Volunteer Services 8025 JCP 200 Hawkins Drive Iowa City, Iowa 52242-1009 319-356-2515 Tel 319-384-8032 Fax www.uihealthcare.org