Download application for volunteer - Southern Ocean Medical Center

■ JERSEY SHORE
UNIVERSITY
MEDICAL CENTER
1945 State Route 33
Neptune, NJ 07754
732-776-4177
■ OCEAN MEDICAL
CENTER
■ RIVERVIEW
MEDICAL CENTER
425 Jack Martin Blvd.
Brick, NJ 08724
732-840-3373
■ SOUTHERN OCEAN
MEDICAL CENTER
1 Riverview Plaza
Red Bank, NJ 07701
732-530-2253
1140 Route 72
Manahawkin, NJ 08050
609-978-3833
“Professional excellence with personal concern”
APPLICATION FOR VOLUNTEER
We are a smoke-free environment.
81746-001cX (7-13)
■ BAYSHORE
COMMUNITY
HOSPITAL
727 N. Beers Street
Holmdel, NJ 07733
732-739-5900
Welcome! We appreciate your interest in meridian health (mh). mh is an integrated health system comprised of acute-care facilities, a regional
tertiary-care facility, long term care residences, physician practices and home care agencies. at meridian, we seek talented and compassionate
individuals interested in providing quality service, demonstrating professional excellence and achieving a high standard of performance. Please
complete the application in ink, giving complete answers to the questions which apply to you.
PLEASE PRINT
Name (LaST)
(FIrST)
(mIddLe)
(area code) home TeLePhoNe No.
PreSeNT addreSS
aPT. No.
cITY
STaTe
ZIP code
e-maIL addreSS
PERSONAL DATA
■
are YoU BeLoW The aGe oF 18?
No
■
(area code) ceLLULar TeLePhoNe No.
JOB DATA
YeS
VoLUNTeer PoSITIoN aPPLYING For:
IF YeS, hoW oLd?___________
haVe YoU BeeN KNoWN BY oTher NameS?
IN caSe oF emerGeNcY caLL
Name:____________________________________________________________________
(
)
area code
PhoNe: __________________________________________________________________
reLaTIoN ShIP: ___________________________________________________________
■
emerGeNcY deParTmeNT
■
TraNSPorT
■
Food SerVIceS
■
PaTIeNT care
■
GreeTer
■
cLerIcaL
■
oTher _______________________________________________________
■
aNY
cIrcLe daYS oF WeeK aVaILaBLe
haVe YoU eVer WorKed/VoLUNTeered aT aNY merIdIaN heaLTh aFFILIaTeS:
VoLUNTeer?
■
YeS
■
No
PaId emPLoYee?
■
YeS
■
No
SaT.
IF YeS, LocaTIoN: _________________________________________________________
daTeS:
SUN.
moN.
TUe.
Wed.
ThU.
FrI.
ShIFT aVaILaBLe
From ___________________________ To _________________________
8:00 am - 12:00 Pm
12:00 Pm - 4:00 Pm
4:00 Pm - 8:00 Pm
deParTmeNT _____________________________________________________________
haVe YoU eVer BeeN deNIed emPLoYmeNT/VoLUNTeer aSSIGNmeNT BY aNY
merIdIaN heaLTh FacILITY?
■
YeS
■
No
IF YoU aNSWered YeS, PLeaSe eXPLaIN, INcLUdING FacILITY aNd daTe:
__________________________________________________________________________
EEO / Affirmative Action Statement: mh does not discriminate against any
applicant or employee because of race, sex, age, religion, creed, national
origin, sexual orientation, disability, veteran status, or any other protected
status in accordance with applicable local, state and federal law.
__________________________________________________________________________
Immigration reform and control act requires I-9 forms verifying alien status
reFerred BY (check one):
■
■
emPLoYee
VoLUNTeer ____________________________________________
be completed within three (3) days of employment.
emPLoYee’S/VoLUNTeer’S FULL Name
emPLoYee’S mh SITe: __________________________________________________________
■
SeLF
■
■
oTher: _______________________________________________________________
ad
■
WeBSITe
Page 1
PROVIDE A COMPLETE LIST OF ALL EMPLOYMENT BEGINNING WITH YOUR MOST RECENT JOB (including military service). Use additional pages if necessary.
NoTe: IF YoU Were emPLoYed UNder aNoTher Name, PLeaSe INdIcaTe IT IN The aPProPrIaTe SPace, To FacILITaTe oUr checKING reFereNceS Needed To VerIFY QUaLIFIcaTIoNS.
comPaNY
addreSS
cITY aNd STaTe
ZIP code
TYPe oF BUSINeSS
Name YoU USed aS emPLoYee
STarTING TITLe
# hrS/WK
Name oF YoUr SUPerVISor
area code
TeL. No.
LaST TITLe
daTeS: From
moNTh
deScrIBe BrIeFLY TYPe oF WorK PerFormed
To
Year
moNTh
Year
reaSoN For LeaVING (eXPLaIN)
are YoU PreSeNTLY emPLoYed
(cIrcLe oNe)
caN We coNTacT YoUr PreSeNT emPLoYer?
(cIrcLe oNe)
comPaNY
YeS
1
No
2
3
addreSS
4
WeeKS
cITY aNd STaTe
ZIP code
TYPe oF BUSINeSS
Name YoU USed aS emPLoYee
STarTING TITLe
# hrS/WK
Name oF YoUr SUPerVISor
area code
TeL. No.
LaST TITLe
daTeS: From
moNTh
deScrIBe BrIeFLY TYPe oF WorK PerFormed
To
Year
moNTh
Year
reaSoN For LeaVING (eXPLaIN)
comPaNY
addreSS
cITY aNd STaTe
ZIP code
TYPe oF BUSINeSS
Name YoU USed aS emPLoYee
STarTING TITLe
# hrS/WK
Name oF YoUr SUPerVISor
area code
TeL. No.
LaST TITLe
daTeS: From
moNTh
deScrIBe BrIeFLY TYPe oF WorK PerFormed
To
Year
moNTh
Year
reaSoN For LeaVING (eXPLaIN)
LIST ADDITIONAL EMPLOYMENT HISTORY: Include Employer Name & Location, Job Held, and Dates of Employment
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Have you ever volunteered before? ■ No ■ Yes
If yes, for what organizations?
_______________________________________________________________________________________from____________ to _____________
_______________________________________________________________________________________from____________ to _____________
_______________________________________________________________________________________from____________ to _____________
Page 2
RECORD OF EDUCATION
Name oF SchooL
addreSS
coUrSe-deGree
dId YoU
GradUaTe?
YeS
No
hIGh SchooL
■
■
coLLeGe
(UNderGradUaTe)
■
■
GradUaTe SchooL
■
■
oTher TraINING reLeVaNT
■
■
■
■
No. oF YearS
comPLeTed
To The JoB YoU are SeeKING
or coUrSeS YoU are
PreSeNTLY TaKING
REGISTRATION: IF reGISTered, cerTIFIed or PoSSeSS a LIceNSe, comPLeTe The FoLLoWING:
__________________________________________________________
____________________________________
reGISTraTIoN or cerTIFIcaTIoN TITLe
__________________________________________________________
NUmBer
____________________________________
reGISTraTIoN or cerTIFIcaTIoN TITLe
NUmBer
_______________
_________________________________
eXPIraTIoN daTe
PLace oF ISSUaNce (cITY or STaTe)
_______________
_________________________________
eXPIraTIoN daTe
PLace oF ISSUaNce (cITY or STaTe)
OTHER SKILLS
COMPUTER SKILLS
CLERICAL
MAINTENANCE
OTHER SKILLS (List)
mS Word
■
carpenter
■
__________________________
excel
■
electrician
■
■
__________________________
Powerpoint
■
Painter
■
cashier
■
__________________________
access
■
Plasterer
■
Shorthand ________wpm
■
__________________________
■ other________________
Plumber
■
Typing ___________wpm
■
__________________________
______________________
refrigeration
■
dictaphone
■
medical Terminology
■
Switchboard
■ other (list)
_______________
MILITARY SERVICE
BraNch oF SerVIce
FINaL raNK
SerVIce NUmBer
SerVIce SchooL or SPecIaL eXPerIeNce GaINed IN The mILITarY SerVIce reLaTed To PoSITIoN aPPLIed For
dId YoU receIVe aNYThING oTher ThaN aN hoNoraBLe dIScharGe?
■
Yes
■
No
If yes, please explain: __________________________________________________________________________________________________________________
are YoU:
■
retired
■
reserves
Page 3
BACKGROUND INFORMATION
have you ever been disciplined or discharged for theft, unauthorized removal of company property or related offenses?
■
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
■
have you ever been discharged for fighting, assault or related offenses?
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
have you ever been disciplined or discharged for being under the influence of alcohol or drugs or
■
for possession or use of alcohol or drugs on the job?
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
■
have you ever been disciplined or discharged for violating safety rules?
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
■
have you ever been disciplined or discharged for insubordination?
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
■
have you had any unauthorized absences in the past year?
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
■
have you ever been disciplined or discharged for unsatisfactory performance?
Yes
■
No
If yes, give details: ___________________________________________________________________________________________________________________
other than traffic violations, have you ever been convicted of a crime which has not been annulled
■
or sealed by the court?
Yes
■
No
If yes, please state the nature of the offense and date of the conviction? _________________________________________________________________________
___________________________________________________________________________________________________________________________________
(conviction does not automatically exclude you from consideration of employment)
Acknowledgement: I understand that this volunteer application and any other MH document are not contracts of employment and that any
individual who is hired may voluntarily leave and may be terminated by MH at any time and for any reason. I understand that no employee or
representative of mh other than the President, has the authority to enter into an agreement for employment for any specified period of time and recognize
that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon.
I understand that my employment with mh volunteer placement may be contingent upon the satisfactory completion of a physical examination including
a drug and alcohol screen and the receipt of a satisfactory recommendation from former employers and references. I recognize further that I may be
required to submit to any additional physical examinations and/or drug alcohol tests as may be required by mh during the course of my volunteering in
connection with the fitness for duty guidelines. I understand mh has a number of facilities and recognize that I may be required to work in facilities and
on shifts other than that to which I am initially assigned.
I certify that the statements made on this application are true and correct, and thereby grant mh permission to verify the information contained herein. I
understand that giving false information or the failure to give complete information as requested herein shall constitute grounds among others for rejection
of my application or my dismissal in the event of my employment.
If I am applying for a position which requires a high school diploma, Ged, undergraduate or graduate degree, license, registration or certification, I
understand I will be required to submit the original document(s) and/or transcripts if applicable, before final acceptance to the position.
_________________________________________________________________________________________________________________________
__________________________________________________________________
SIGNaTUre
daTe
Page 4
■ JERSEY SHORE
UNIVERSITY
MEDICAL CENTER
■ OCEAN MEDICAL
CENTER
1945 State Route 33
Neptune, NJ 07754
732-776-4177
425 Jack Martin Blvd.
Brick, NJ 08724
732-840-3373
■ RIVERVIEW
MEDICAL CENTER
■ SOUTHERN OCEAN
MEDICAL CENTER
1 Riverview Plaza
Red Bank, NJ 07701
732-530-2253
1140 Route 72
Manahawkin, NJ 08050
609-978-3833
■ BAYSHORE
COMMUNITY
HOSPITAL
727 N. Beers Street
Holmdel, NJ 07733
732-739-5900
department of volunteer ServIceS health queStIonnaIre
(print or type all information on the following pages)
Volunteer’s Name:_____________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Town
Zip
Street
Telephone #:__________________________________________________ Date of Birth: ____________________________________
Section I: To be completed by all applicants. (For chicken pox, rubella, rubeola and mumps, please refer to the
exposure chart on page 2 to answer the following questions.)
Have you ever had varicella (chicken pox)?
Have you ever been exposed to anyone with chicken pox?
Have you ever had a varicella titer (test)?
Yes
Yes
Yes
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Have you ever had Hepatitis?
Yes
No
If yes, date and type: ______________________________________________________________
Have you ever been exposed to anyone with Hepatitis B?
Have you ever had the Hepatitis B vaccine?
Yes
Yes
No
No
If so, what are the dates of vaccine? ______________ ______________ ______________
Have you ever had the Hepatitis B surface antibody and antigen testing done?
Yes
No
Yes
Yes
No
No
If yes, date and results: ____________________________________________________________
We require that all volunteers born after December 31, 1956 provide proof of MMR vaccination.
Have you ever had the MMR (measles, mumps, and rubella) vaccine?
If so, when? _____________________________________________________________________
Have you ever had the German measles (rubella)?
Have you ever been exposed to anyone with german measles?
Have you ever had a rubella titer (test)?
If yes, date and results: ____________________________________________________________
Have you ever had measles?
Have you ever been exposed to anyone with measles?
Have you ever had a rubeola titer (test)?
If yes, date and results: ____________________________________________________________
Have you ever had mumps?
Have you ever been exposed to anyone with mumps?
Have you ever had a mumps titer (test)?
If yes, date and results: ____________________________________________________________
Section II: To be completed by all applicants. (PPD and Hepatitis B)
If yes, date and results: ____________________________________________________________
Have you ever had tuberculosis (TB)?
If yes, did you receive treatment?
81746-005CX (8-13)
If yes, type of treatment and date: ____________________________________________________
Have you ever been exposed to anyone with TB?
Yes
No
If yes, where and when? ___________________________________________________________
Were you treated?
Yes
No
If yes, type of treatment and date:___________________________________________________________________________
Have you ever had a Mantoux (PPD/TB screening) test?
Yes
No
If yes, date: ____________________________________________________________________________________________
What was the result of your PPD? Negative___________ Positive___________
If positive, have you had a recent chest x-ray?
Yes
No
If yes, what were the results? ______________________________________________________________________________
If positive, please have your physician complete a Symptom Review Sheet. (This is available from the Occupational Health Department.)
exposure chart for diseases
chicken pox – Spending time with person 4-5 days before rash appears until days after rash appears.
German measles (rubella) – Spending gime with person 7 days before rash appears until 4 days after rash appears.
measles (rubeola) – Spending time with person 4 days before rash appears until 3 days after rash appears.
mumps – Spending time with person 6-7 days before swollen glands appear until 9 days after swollen glands appear.
tuberculosis (tB) – Spending time with a person with tuberculosis.
hepatitis B – Direct contact with blood or bloody fluid from an individual with know and active Hepatitis B.
Volunteer’s Name:_____________________________________________________________________________________________
Section III: To be completed by all applicants.
Are you currently under the care of a physician for any medical condition?
Yes
No
If yes, please indicate: _________________________________________________________________________________________
___________________________________________________________________________________________________________
Please list any know allergies: ___________________________________________________________________________________
______________________________________________________________________
Volunteer’s Signature
_________________________________
Date
Section Iv: To be completed and signed by your physician.
I have reviewed the health history of the aforementioned volunteer applicant and the following holds true:
This individual is free from contagious disease.
This individual is able to perform physical duties to tolerance.
Yes
Yes
No
No
Limitations: __________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please list any medications that this patient is currently taking:__________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Doctor’s Name (please print or type)
___________________________________________________________________________________________________________
Address
______________________________________________________________________
Doctor’s Signature
_________________________________
Date