Shriners hospitals for children-galveston burns hospital
FOR HOSPITAL USE ONLY Volunteer Application Interview Date (Individual) PERSONAL INFORMATION
Do you have any physical limitations or special needs that should be considered in your placement?
Are you volunteering to meet any specific requirements (Community Service Hours, etc.) for a specific reason?
Have you ever been convicted of, on probation for, and/or received deferred adjudication for, or are awaiting trial for, any felony or misdemeanor?
If yes*, please explain and provide dates:
* Criminal history will not necessarily disqualify an applicant.
PERSONAL REFERENCES (exclude relatives) 815 Market St, Galveston, TX 77550 * Main 409.770.6600 * Fax 409.770.6563 CURRENT EMPLOYMENT STATUS
Current Employment Status (check only one)
Check highest level of education completed:
Associate’s Degree / Completed 2 Yrs College
Brief description of duties/responsibilities:
If yes, with what computer programs are you familiar:
If no, would you like to learn the computer?
Would you be comfortable answering the telephone?
Are you fluent in any language(s), other than English? SPEAK WRITE
List any other skills, interests, certifications, or special abilities we should take into consideration.
INTERESTS & AVAILABILITY
Please indicate the type of service(s) you would most prefer to do in our hospital:
* If interested in the Pet Partners Program please list type of pet, and provide a copy of your Pet’s Certificate of Training. List type of pet here: __________________________________
815 Market St, Galveston, TX 77550 * Main 409.770.6600 * Fax 409.770.6563
Check days and provide specific times you are available to work for each. DAY MORNING AFTERNOON EVENING
How long do you expect to be a volunteer for Shriners Hospitals for Children – Galveston?
Why do you want to volunteer at Shriners Hospitals for Children – Galveston?
How did you learn about Shriners Hospital volunteer services?
I understand and hereby consent that my photograph may be taken for the purpose of promotion of
services at Shriners Hospitals for Children. I am aware that I will not receive payment of any kind for my participation and grant Shriners Hospitals for Children the rights to their use for my future association with the hospital and for an unrestricted time.
I am interested in joining the Shriners Hospitals for Children – Galveston Auxiliary. I understand that the Auxiliary requires an initial membership payment of $5.00, due prior to starting your first work day. After which a vote of approval will take place during the next Board Meeting. The Auxiliary board meets the 1st Wednesday of each month. Upon approval, annual dues of $5.00 will be expected. Additionally, I understand that certain rules & regulations, separate from those of the hospital, are to be adhered to as a member of the Auxiliary. I certify that all information contained in this application is true and authorize its investigation, and hereby release all parties from any liability arising from such investigation. I also agree that any false statement, misrepresentation, or omission of facts on this application, regardless of when discovered, will result in immediate dismissal. Should I be accepted as a Shriners Hospitals for Children - Galveston Volunteer, I have no expectation of remuneration for the services I will provide.
Signature Date 815 Market St, Galveston, TX 77550 * Main 409.770.6600 * Fax 409.770.6563 PRE-VOLUNTARY DISCLOSURE & RELEASE
Any other name you have volunteered under:
Pursuant to the requirements of the Fair Credit Reporting Act, I acknowledge that a consumer report1 and/or investigative consumer report2 may be made in connection with my application for volunteering with prospective facilities. I understand that these investigative background inquiries may include credit, consumer, criminal, driving, prior volunteering, and other reports. These reports may include information as to my character, work habits, performance, and experience, along with reasons for termination of past volunteering from previous facilities. Further, I understand that agents may be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil, and other experiences, as well as claims involving me in the files of insurance companies.
I authorize, without reservation, any party or agency to furnish the above mentioned information. A photocopy of this authorization shall have the same effect as the original.
I understand the information obtained will be used as one basis for volunteering or denial of volunteering. I hereby discharge, release, and indemnify prospective school, their agents, servants and schools, and all parties that rely on this release and/or the information obtained with this release from any and all liabilities and claims arising by reason of the use of this release and dissemination of information that is false and untrue if obtained from a third party without verification.
It is expressly understood that the information obtained through the use of this release will not be verified by investigating agents.
The authorization granted herein expires one year from the date hereof.
I have read and understood the above information, and assert that all information provide by me is true and accurate.
If you are under the age of eighteen, the signature of a parent or guardian must be obtained.
If you are denied voluntary, either wholly or party because of information contained in a consumer report, a disclosure will be made to you of the name and address of the investigative agency making such report. Upon your written request within a reasonable period of time, the investigative agency compiling the report will make a complete and accurate disclosure of the nature and scope of the investigation.
1 A consumer report may consist of enrollment records, educational verification, licensure verification, driving record, previous address and public records relative to criminal charges. 2 An “Investigative Consumer Report” means a consumer report or portion thereof in which information on a consumer’s character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with person having knowledge 815 Market St, Galveston, TX 77550 * Main 409.770.6600 * Fax 409.770.6563 TUBERCULOSIS SKIN TEST DOCUMENTATION Employee / Volunteer Name: Social Security Number: Tuberculin Purified Protein Derivative (PPD) for intracutaneous (Mantoux) tuberculin testing:
Date Administered: _______________ Site: ________Rt. ______Left (forearm) Dose/Route 0.1 ml of 5 Tuberculin Units, intradermal (intracutaneous) or otherwise as follows: ____________________________________________________________________________ Name of Person Applying Test: ______________________________________ ______________________________________ Print Name Signature and Title
Interpretation of Tuberculin PPD Skin Test:
Date of Reading: __________________ Millimeters (MM) Induration: ___________________ Vesiculation/Ulceration/or Necrosis at Test Site _______ Yes _______ No Name of Person Who Read Test: ______________________________________ ______________________________________ Print Name Signature and Title
Return Documentation form to:
Shriners Hospitals for Children – Galveston (Volunteer Department)
SHRINERS HOSPITALS FOR CHILDREN-GALVESTON OCCUPATIONAL HEALTH HISTORY QUESTIONAIRE PERSONAL HEALTH HISTORY
Have you ever had, or do you have, any of the following? If yes, please indicate the year in which it occurred. Skin problems or chronic rash
51. Have you ever had a motor vehicle accident resulting in injury?
52. Have you ever had a work related injury or illness?
Needle sticks/blood or body fluid exposures
b) Rash or symptoms related to glove use
Pain, numbness, or tingling related to repeated hand/wrist motions or keyboard use
54. Are you presently under a health provider’s care of any condition?
55. Please list the dates and reason for your last medical examination
56. Have you ever had an illness or injury since your last medical examination?
57. Have you ever been hospitalized or had an operation?
58. Have you ever had a reaction, allergy and/or sensitivity to drugs, food, plants. animals, latex gloves, or any other substances?
Please describe any YES answers from questions 51-58. Include dates: I HERBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS HEALTH QUESTIONNAIRE FOR EMPLOYEMENT UIS TRUE AND CORRECT AND ANY OMMISSION OR MISREPRESENTATION OF FACTS WILL BE A BASIS FOR IMMEDIATE DISMISSAL.
SHRINERS HOSPITALS FOR CHILDREN-GALVESTON NATURAL RUBBER LATEX (LATEX) SCREENING FOR EMPLOYEES AND STAFF
The questions in the questionnaire may identify food allergies, medications or medical and surgical history that are sometimes found in people who have latex allergy. A positive response to any of the following questions means additional information may be needed to make a determination whether you should avoid contact with latex. The Employee Health Nurse will evaluate your responses and make any recommendations regarding latex that you may need. Answer each question. If a question does not apply to you, leave the field blank. DEFINITIONS FOR WORDS IN THE TOOL Anaphylactic: An allergic reaction so severe it may be life-threatening. These occur very rarely. Congenital Abnormalities: A deformity or skeletal problem you are born with. The most important are those that require surgery to correct. E.g. spina bifida (sometimes called “open spine.”) Latex Birth Control Devices: Condoms and Diaphragms. Dental Cofferdams: A latex (rubber) barrier (sometimes called “dam”) placed in the mouth during procedures, e.g. when capping teeth. FURTHER QUESTIONS Why is it important if I am on specific medications? The listed medications are beta-blockers. If a person is on a beta-blocker medication and has a mild natural latex rubber allergy, the beta-blocker medication could cause the person to have an allergic asthmatic attack because the medication and the allergy both cause the lung to tighten up. This tool is not intended to be all-inclusive. Individuals who are uncertain whether they are or may be sensitive to natural rubber latex should consult their physician. Employee Name: ____________________________ Dept/Rm:________________________ 1. Have you ever had an anaphylactic reaction to latex device/products?
5. After handling latex products, have you experienced any of the following? Difficulty breathing
6. Do you have a history of the following? Contact dermatitis
Recent Long- Recent Long Recent Long Recent Long-
onset standing onset standing onset standing onset standing
If yes, describe the reaction: 8. Do you take any of the following medications?
Leticia Esperanza Medina Esparza Lugar y fecha de nacimiento: Aguascalientes, Ags. Domicilio: Teléfono: PERFIL PROFESIONAL Profesión: (1979-1984) Universidad Autónoma de Ags. Cédula profesional: Maestría: (2001-2003) Universidad Autónoma de Ags. Cédula de maestría: Doctorado: Cedula de doctorado: Antigüedad en el trab
Honahlee, PC MARE CONTRACT Name of Owner: ________________________________________________________________ Address: ______________________________________________________________________ ______________________________________________________________________________ Email: ________________________________________________________________________ Contact Person: ________________________