Test Date MM DD YYYY Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneMobile PhoneEmail Birthday MM DD YYYY Emergency ContactEmergency Contact PhonePlease list any special skills, training or expertise that you have (medical, specialty, carpentry, painting, computer graphics, fundraising). Do you speak any languages other than English? Please list the languages you speak.Where else do you currently work or volunteer and what do you do there?What volunteer position(s) are you interested in at VIM? Clinical Positions: Nurse-Clinical Assistant Patient Case Manager Social Worker Mental Health Services Nurse/Clinical Assistant: Please check your titleAPRNRNMANPRTLPNOtherOther TitlePatient Relations Positions Greeter — Patient Sign-In, Assist Patient with Paperwork, Requires no Computer Work Screener — Interviews patient for eligibility, enters patient data into computer Scheduler — Schedules patient's appointments with physician on computer Scanner — Scans patients documents into electronic medical records Special: Traffic Controller — Assists with parking directions and safety What are your preferred days/hours to volunteer? Please check.MondayTuesdaysWednesdaysThursdaysFridaysMorningsEveningsAfternoonsVolunteer Code of ConductThe primary mission of the Volunteers in Medicine Clinic is to understand and serve the health and wellness needs of the medically underserved population living and/or working in Bluffton and Jasper County. In working with our patients, their confidentiality is of utmost importance to the work we do here. I shall: 1. Uphold the philosophy and standards of VIM; 2. Not seek to obtain confidential information from a patient unless it is in the course of my job responsibilities; 3. Maintain all information that I obtain concerning patients, doctors and staff as confidential. 4. Conduct myself with dignity, courtesy and consideration of others, and endeavor to be professional; 5. Be punctual, conscientious and dependable; 6. Make my best effort to fulfill my commitment to VIM by completing all assignments; and 7. Bring to the attention of the Coordinator of Volunteers any problems that impact my ability to meet the above standards, or that impact the VIM standards. I agree to: 1. Wear my ID badge; 2. Review the schedule and alert the Coordinator of Volunteers of any scheduling conflicts; and 3. Submit to immunizations (TB, Hepatitis B, etc.) that may be necessary. I understand that VIM reserves the right to terminate my volunteer status as a result of: 1. Failure to comply with VIM policies, rules and regulations; 2. Excessive absences without prior notification; 3. Unsatisfactory behavior or attitude not in the spirit of VIM; and 4. Any other circumstance that would make my continued service contrary to the best interest of VIM.Terms and Conditions* I have read each of the above conditions and agree to abide by them. By clicking above, you are submitting this as your electronic signature.Health InformationHealth policy for Medical, Dental. Nursing, Specialized Professionals, Lay Volunteers : pplicants are qualified to volunteer if their physical and mental health will not impair their ability to render quality patient care. When the Medical Director has a reason to question the physical and/or mental status of the volunteer, the volunteer will be asked to submit to an evaluation of their physical and/ or mental health status. This evaluation will be a prerequisite for further consideration of their application for appointment or re-appointment. If a volunteer's health tatus changes to the point where they are unable to perform their duties, they may be considered for a more appropriate duty. Condition of Appointment All volunteers must fulfill the following: 1 Read and click the below agreement to the Attestation of Health Form; 2. Employees and volunteers working in direct patient care areas will be asked to provide evidence of Hepatitis B vaccination series, agree to receive the vaccine, or sign a waiver to refuse the series. For all other employees and volunteers whose normal work involves no exposure to blood, body fluids, or tissues no protective measures need to be taken; and 3.A tuberculin skin test is required yearly and is provided by the VIM Clinic. A volunteer with a positive TB test will be referred to her /his private physician for a chest x-ray and follow-up. In the event that a volunteer is found to have a positive TB skin test prior to the beginning of clinical duties, the volunteer will need to provide a note from her /his private physician.Name First Last * I attest and can document, if necessary, that I am currently free of any physical or mental ailments that would impair my ability to perform my duties as a volunteer. I am free of addiction to drugs, alcohol, or any other recreational chemical substances. I understand that I may not hold VIM responsible for ailments that I have disclosed or have not disclosed. Known Medical Allergies or Adverse Reactions:Please list the medication allergy and the type of reaction.Physician's NamePhysician's PhoneOptional Information: List any medical condition of which you would like us to be aware, even though these conditions do not impair your ability to perform as a volunteer. List medication that you are currently taking. This information is needed should you require medical assistance on an urgent or emergency basis while volunteering at the Clinic. Information will be held strictly confidential under the Health and Information Portability and Accountability (HIPAA) law.Agreement* By clicking here you are admitting this as your electronic signature. NameThis field is for validation purposes and should be left unchanged.