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■ 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