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• Welcome Letter |
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MCV Hospitals at the VCU Medical Center VOLUNTEER DATA SHEET Date _________
Ms. Mrs. Miss Mr. _________________________________________ Dr. Last Name First Name Middle Initial
Name you prefer to be called ____________________ SS# __________________
Home Address __________________________________ Street Box Number or Both
________________________________________________ City Zip Code
Home Phone #_____________________________ Business Phone #__________________________
Email Address ____________________________ Date of Birth _____________________________
Occupation _______________________________ Place of Employment _______________________
Previous Volunteer Experience ______________________
________________________________________________ ________________________________________________
Education _______________________________________ Do you have experience working in a hospital environment and if so, where was it? __________________________________________________
__________________________________________________
Have you ever been charged with a misdemeanor or convicted of a felony? _____________________ If yes, please explain ____________________________________________________ ____________________________________________________ Do you have a preference about where you wish to volunteer? _____________________________________________________ _____________________________________________________
Days and times preferred ________________________________ ______________________________________________________ ______________________________________________________
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MCV Hospitals at the VCU Medical Center – Volunteer Data Sheet – pg. 2 Service Area preferred____________________________________ Please give the names, addresses and telephone nos. of two references ______________________________________________________ ______________________________________________________ Contact in case of emergency: Name_____________________________________ relationship_________________ Address________________________________________ phone # _______________ I hereby apply for volunteer work with the MCV Hospitals at the VCU Medical Center. I understand and agree to comply with regulations and requirements of the hospital. Should I stop volunteering, my hospital ID will be returned. I also understand that as a volunteer that I have the right to say no to any job asked of me with which I feel uncomfortable. _______________________________________________ ________ Signature Date ******************************************************** CONFIDENTIALITY STATEMENT
In my role as a volunteer of the MCV Hospitals at the VCU Medical Center, I understand that:
1. I MUST NOT discuss patients or their family members and their medical problems with others either inside or outside the facility.
2. If I have access to written reports such as medical charts, I will not discuss the information contained therein.
3. I will not suggest diagnosis or methods of treatment to any patient or their family members.
4. I understand that each breach of confidentiality could result in a $5,000 fine per offense and in my immediate and permanent dismissal from the MCV Hospitals at the VCU Medical Center.
By signing this affirmation, I agree to uphold the confidentiality of patients/families and understand the consequences of a breach in confidentiality.
________________________________________________ __________ Signature Date |
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