Sibley Volunteers How to Apply

Sibley Volunteers How to Apply Thank you for your interest in becoming a Volunteer at Sibley Memorial Hospital. Please read the guidelines and rules that apply to Volunteers. All application forms should be submitted together as a packet. Incomplete application packets will not be filed or reviewed. Availability is limited and based on Hospital need. Applicants will be contacted by email or phone for an interview. Commitment of Hours: Volunteers commit to a minimum of four hours a week within a six month period or 100 total hours of service. Please read: Volunteer Guidelines Volunteer Medical Requirements Submit the following items together: Junior applicants: Application Availability form Medical Clearance Form (Must be completed on your behalf by a licensed provider) Proof of current Influenza Vaccination (Mandatory during flu season) Proof of an updated PPD (within the year) School Recommendation Form- To be completed by a school counselor, teacher or administrator. (Enclosed in a signed and sealed envelope) Personal Reference (Enclosed in a signed and sealed envelope) Essay Adult applicants: Application Availability form Medical Clearance Form (Must be completed on your behalf by a licensed provider) Proof of current Influenza Vaccination (Mandatory during flu season) Proof of an updated PPD (within the year) References- Please submit two references. At least one from a supervisor, work colleague or instructor (former or current) is preferred. (2 required; enclosed in signed and sealed envelopes) Essay You may mail or personally deliver your application packet to the Volunteer Office. The Volunteer Office is located in the lobby of the Main Hospital Building. Sibley Volunteer Service Phone: 202.537.4485 5255 Loughboro Rd, N.W. Washington, DC 2006 Washington, D.C. 20016 Website: http://www.h

Interview You will meet with the Director of Volunteer Service or Volunteer Representative to talk about the Volunteer Guidelines and medical requirements, ask questions, indicate your assignment preferences (if any) and set up orientation and training dates. You will take a quiz over hospital policies and procedures. Applicants 18 and older will complete an authorization for a criminal background investigation. Orientation Volunteers must complete a 2-hour training session prior to starting their service. Attendance and Conduct Volunteer Office reserves the right to dismiss any participant due to unexcused absences or unacceptable behavior. Documentation of Volunteer Hours Sibley Memorial Hospital Volunteers may request documentation of their service. Volunteer may request documentation of hours ONLY after their commitment of hours has been completed.

Sibley Volunteer Service Volunteer Guidelines Thank you for your interest in becoming a Volunteer at Sibley Hospital. Please read the guidelines and rules that apply to Volunteers. All application forms should be submitted at the same time in a complete packet. Incomplete application packets will not be filed or reviewed. Those applying for the Summer Program must complete the Summer Availability form and adhere to the stated deadline. Applicants will be contacted via email or phone to schedule an interview. I. REQUIREMENTS Age: At least 15 years of age. Application Packet: Junior (Under 18): Application form Availability form Medical clearance form (including proof of flu vaccination during flu season and updated PPD) School recommendation form (to be enclosed in a sealed and signed envelope) Personal reference (to be enclosed in a sealed and signed envelope) Personal essay: Why I Would Like to be a Sibley Volunteer Adult: Application form Availability form Medical clearance form (including proof of flu vaccination during flu season and updated PPD) 2 Personal references (to be enclosed in a sealed and signed envelope) Personal essay: Why I Would Like to be a Sibley Volunteer Interview: You will meet with the Director of Volunteer Service to talk discuss your interest in volunteering, ask questions and indicate your assignment preferences (if any). You will take a quiz over Hospital policies and procedures. Applicants 18 and older will complete an authorization for a criminal background investigation. Enrollment is based on Hospital need. Medical: Medical requirements must be completed BEFORE service begins. Medical clearance form (must be completed by a licensed provider) Annual PPD (Tuberculosis screening) for all Volunteers. Volunteers may have this test at Sibley at no charge or may schedule the test with a private physician at their own expense. Annual influenza vaccination. Volunteers declining vaccination for medical or religious reasons must submit an appeal to Johns Hopkins Medicine for approval. ALL SIBLEY VOLUNTEERS MUST COMPLETE A DRUG TEST GIVEN BY EMPLOYEE HEALTH. All VOLUNTEERS ARE ALSO SUBJECT TO DRUG TESTING FOR CAUSE. Training: Volunteer Orientation (typically two hours) and training in your service area (varies by department).

ATTENDANCE AND ABSENCES Volunteers become an integral part of their department and the Hospital staff relies on their presence as scheduled. We understand that all volunteers may get sick, take vacations or have unavoidable conflicts on their regular volunteer day. It is the volunteer s responsibility to obtain the telephone number(s) of the assigned department and notify them directly in the event of tardiness or absence. A message may also be left on the Volunteer Office answering service, but this does NOT relieve you of the responsibility to your department. Volunteers who have taken an extended leave of absence must contact the Director of Volunteers before returning to service. Please do not arrange for a reentry schedule with your service chairman or department without notifying the Director. Similarly, please notify the Director if you are resigning from the Volunteer Service and return your ID badge. II. DRESS CODE Each Volunteer is required to wear a uniform item issued by the Volunteer Office to wear on the job. Polo shirts & sweaters are available for all Volunteers. Khaki slacks should be worn. All Volunteers must wear closed, comfortable, clean shoes or sneakers with socks (or hose). Uniform Prices Volunteers receive one uniform item free of charge during Volunteer Orientation. Additional items are offered upon request and will be charged as listed below. Polo Shirt $10.00 Sweater $20.00 Vest $15 Volunteers obtain uniforms from the Volunteer Office BEFORE their first date of service. Checks for uniforms are payable to Sibley Volunteer Service. Long hair should be pulled back and earrings should be conservative. Please do not use perfume or other scented products as it may cause allergic reactions in some patients. III. VOLUNTEER ASSIGNMENT AND SCHEDULES You will be given one or more regular volunteer assignments based upon the needs of the Hospital. Every effort will be made to take into account your special interests and skills. IV. SIGN-IN PROCEDURE AND LOCKERS When you arrive for your shift, sign in on the computer in the Volunteer Office. When you leave for the day, sign out using the computer. Lockers are available for storage of your personal belongings. Please do not bring valuables or cash to the Hospital that you do not absolutely need. You must bring your own lock for the lockers. V. ONGOING EDUCATION Volunteers are expected to read all email from the Volunteer Office and correspond accordingly. Education Day tests must be updated annually or upon request. VI. MEAL BREAKS Your Volunteer Photo ID entitles you to discounted meals in the Sibley cafeteria at any time, whether you are here to work your shift or are visiting the Hospital for other reasons. VII. PARKING Volunteers are entitled to free parking in the Visitor s Parking Garage. *PLEASE NO CELL PHONE USE DURING HOURS OF SERVICE*

Sibley Memorial Hospital Occupational Health/Safety 5255 Loughboro Road, N.W. Washington, DC 20016-2695 202-537-4265 T 202-537-4442 F MEMORANDUM TO: FROM: SUBJECT: Sibley Memorial Hospital Volunteers Sibley Occupational Health and Safety Medical Requirements for Volunteers At the recommendation of the Johns Hopkins Hospital Epidemiology and Infection Control (HEIC) Department, Sibley Memorial Hospital now requires proof of measles, mumps, rubella and varicella immunity in addition to documentation of TDaP administration of all hospital staff and volunteers. Patient safety is the key goal of this requirement. Some of our patients are too young to be immunized against vaccine preventable diseases and are at increased risk of complications from these diseases and many others are at increased risk due to acute or chronic illnesses. Immunizing hospital staff helps to safeguard patients from the risks and complications of these potentially deadly diseases. Under this policy, all Sibley Memorial Hospital employees and volunteers must provide: Documented proof of immunity to Measles, Mumps, Rubella, TDaP and Varicella Documented proof of Hepatitis B immunity is strongly encouraged, although not required A medical clearance form will be provided to all volunteers. The form must be completed by a licensed ind ependent provider. Self-reporting will not be accepted. Requirements are listed below. 1) Documented proof of Measles, Mumps and Rubella exposure. If you were born BEFORE 1957 you have acceptable evidence of measles, mumps and rubella immunity. This needs to be indicated by checking the box on the form. If you were born AFTER 1957, one of the following must be indicated on your form: o Dates of measles, mumps and rubella vaccines or MMR combo vaccine (2 doses required). o Documentation of measles, mumps and rubella illnesses. This must be noted in your medical record, not self-reported. o Laboratory evidence of immunity by titer. 2) Documented proof of Varicella (chicken pox) exposure. You must submit one of the following acceptable forms of proof: Date of VariVax (chickenpox vaccine). Documentation of being ill from chicken pox or shingles. This must be noted in your medical record, not selfreported. Laboratory evidence of immunity by titer. Blood can be drawn for varicella zoster virus antibodie s. Documentation of receiving Zostavax (shingles vaccine). 3) Documented proof of TDAP (Tetanus, Diphtheria, Pertussis) vaccination. 4) SEASONAL INFLUENZA VACCINE AND TUBERCULOSIS SCREENING WILL CONTINUE TO BE REQUIRED ANNUALLY. Volunteers may request an exemption to vaccine requirements based on certain medical conditions or on the basis of sincerely held religious beliefs. Volunteers must submit documentation of any medical contraindications to receiving vaccines to Occupational Health and Safety. Requests for religious accommodations should be submitted to Human Resources (Refer to HR Policy #03-21-81 Religious Accommodations). Please feel free to contact Sibley Occupational Health at (202) 537-4265 with any questions or concerns.

SIBLEY MEMORIAL HOSPITAL VOLUNTEER AVAILABILITY Name: Email address: Phone number: Proposed start date: Proposed end date (if applicable): I am available to work the following shifts: morning 8:30 am 12:30 pm afternoon 12:30 pm 4:30 pm evening 4:30 pm 8:30 pm Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total hours per week preferred: Please indicate below any special requests.

QUESTIONS? Contact Volunteer Service 202. 537. 4485 SIBLEY MEMORIAL HOSPITAL VOLUNTEER APPLICATION Today s Date: I am applying for: Adult Junior Summer Year-round APPLICANT BACKGROUND INFORMATION: First Name Last Name Nickname Cell Phone Home Phone Work Phone E-Mail Address (print clearly) Address (Street, Apt #, City, State, Zip) SEX: Female Male Date of Birth (optional except for those under 18): I CONSIDER MYSELF TO BE PRIMARILY A: Student Working Professional Retiree Adult in the community, not working Other: EDUCATON: Please indicate your highest level of schooling completed or current year in school: High School 1 2 3 4 College 1 2 3 4 Graduate School 1 2 3 4 Name of most recent/current school: _ Degree/Major: HIGH SCHOOL STATUS: I am a high school student Yes No EMPLOYMENT: Current Employer: Position/Title: EMERGENCY CONTACT: Name: Relationship: Cell Phone Home Phone Work Phone E-Mail Address (print clearly)

WORK PREFERENCE: I would like to request patient contact: Yes No In addition, I am interested in a specific placement if available: SCHEDULE: Proposed start date Proposed end date How many hours a week would you like to volunteer? (Minimum commitment is 4 hours a week). Are you fulfilling a community service requirement or prerequisite for a degree program or school? Yes No If yes, please indicate total number of hours required: Are you interested in working in the medical field in the future? If yes, please describe: RECOMMENDATIONS: Recommendations are not to be provided by family members. Forms can be found on the website. Adult Volunteers: Please provide two recommendations. At least one from a current or previous job supervisor, teacher, advisor or coworker is preferred. High School Volunteers: Please provide two recommendations: One from your School Guidance Counselor or Community Services/Internship Coordinator, and one from an after-school activity advisor, coach, teacher or job supervisor. COMMITMENT OF HOURS If accepted as a Sibley Memorial Hospital Volunteer, I commit to volunteer at Sibley for either 1) a minimum of four hours a week within a six month period; 2) 100 total hours of service or 3) one or more of the scheduled summer sessions. I understand that I may request letters of recommendation only after fulfilling my commitment of hours. Signature: Date: PERSONAL STATEMENT In choosing to apply to become a Sibley Volunteer, I am interested in donating my time and effort to Sibley Memorial Hospital. I understand that in order to become a Sibley Volunteer, if I qualify, I will need to complete the application process including attending Volunteer Orientation that emphasizes key components of Sibley Memorial Hospital Volunteer Program. I hereby certify that I have read and understand all of the statements and questions on this application and that my responses are true and complete to the best of my knowledge. I understand that misrepresentation, falsification or omission of information may disqualify me from volunteer service. I recognize that inappropriate behavior can result in immediate dismissal from the program. As Parent/Guardian, I have read and understand the requirements and commitments for my son/daughter to volunteer at Sibley Memorial Hospital and hereby grant full permission for his/her participation in the program as a High School Volunteer. Applicant Signature: Parental/Guardian (if under 18) Signature: Date: Date:

VOLUNTEER REFERENCE FORM Sibley Volunteer Service 5255 Loughboro Road, NW Washington, DC 20016 P: 202.537.4485 APPLICANT S NAME TO THE VOLUNTEER APPLICANT: This form should be given to two people to whom you are not related. Each reference should complete the form. This form is NOT to be filled out by the applicant. TO THE REFERENCE: The person named above is applying to become a Volunteer at Sibley Memorial Hospital. Please complete this reference form and return it to the applicant so that it may be submitted with the application packet. You may contact our office if further comments are necessary. Please TYPE or PRINT clearly. Name Relationship to Applicant Address Phone How long have you known applicant? What are the first words that come to mind to describe the applicant? Would you have any reservation in recommending the applicant to participate in the Sibley Memorial Volunteer Service Program? Why or why not? Please use this space to include anything else about the applicant that may help in determining his/her qualifications. Feel free to attach further comments. I hereby certify that my responses are true and complete to the best of my knowledge. Initial and Date

VOLUNTEER REFERENCE FORM APPLICANT S NAME TO THE VOLUNTEER APPLICANT: This form should be given to two people to whom you are not related. Each reference should complete the form. This form is NOT to be filled out by the applicant. TO THE REFERENCE: The person named above is applying to become a Volunteer at Sibley Memorial Hospital. Please complete this reference form and return it to the applicant so that it may be submitted with the application packet. You may contact our office if further comments are necessary. Please TYPE or PRINT clearly. Name Relationship to Applicant Address Phone How long have you known applicant? What are the first words that come to mind to describe the applicant? Would you have any reservation in recommending the applicant to participate in the Sibley Memorial Volunteer Service Program? Why or why not? Please use this space to include anything else about the applicant that may help in determining his/her qualifications. Feel free to attach further comments

Volunteer Services Department 5255 Loughboro Rd NW Washington, D. C., 20016 202-537 - 4485 VOLUNTEER MEDICAL CLEARANCE FORM This document must be completed by a licensed independent provider. All information contained in this document is strictly confidential. Name (Last, First, M.I.): M F DOB: IMMUNIZATIONS MMR (measles, mumps, rubella): Please provide laboratory evidence of immunity by titer, documented illness or two doses of MMR. Note: If born before 1957, you have acceptable presumptive evidence of measles, mumps and rubella immunity. Immunizations and dates: MMR Dose#1 (Combo vaccine) Dose#2 Rubella Dose #1 Dose #2 Titer Date: Immune (Y) (N) Dose#1 Titer Date: Measles Single Immune (Y) (N) Vaccine Dose #2 Born before 1957 Mumps Dose#1 Dose #2 Titer Date: Immune (Y) (N) MMR Dates of Illness: Measles Mumps Rubella VZV (Varicella): Please provide laboratory evidence of immunity by titer, documented shingles vaccine, documented illness or two doses of varicella vaccine. VariVax Dose #1 Titer Date: (Varicella Vaccine) Shingles Vaccine Date: Dose #2 Immune (Y) (N) Chickenpox Date of Illness: TDAP (Tetanus, Diphtheria, Pertussis) Date: Volunteer applicants will need one time dose of TDAP regardless of when previous dose of Td was received. Volunteers will need Td boosters every 10 years thereafter. Hepatitis B Vaccine Providing proof of laboratory evidence of immunity by titer or three doses of hepatitis b vaccine is optional. Dates: Dose #1 Dose #3 Influenza Vaccine Date: Dose #2 Titer Date: Immune (Y) (N) During influenza season, all volunteers are required to provide documented proof of vaccine administration. Volunteers declining the vaccine for medical or religious reasons must submit an appeal to Johns Hopkins Medicine.

Volunteer Services Department 5255 Loughboro Rd NW Washington, D. C., 20016 202-537 - 4485 PHYSICAL AND EMOTIONAL HEALTH ASSESSMENT The above volunteer applicant is free from contagious or debilitating disease. Yes No The above volunteer applicant is able to transport and discharge patients and stock supplies (minimum 25lbs). Yes No The above volunteer applicant is able to perform extensive walking, sitting, bending, stooping and standing. Yes No The above volunteer applicant is able to push carts for delivering flowers and packages. Yes No The above volunteer applicant is able to push patients in wheelchairs for discharges (minimum 50lbs push/pull force) Yes No The above volunteer applicant is physically able to safely handle wheelchairs in connection with patient admissions and discharges and to walk throughout the hospital. Yes No In my judgment, applicant is both physical and emotionally stable, and there is no reason why applicant should not be able to perform the demanding tasks of Volunteer activity at Sibley Memorial Hospital. Yes No Licensed Independent Provider s Signature Date Address Telephone *PLEASE ATTACH PROOF OF AN UPDATED PPD (TUBERCULOSIS TEST).*

Personal Essay Requirement Why volunteer at Sibley? The answers vary. Some volunteers have been patients or have had family members who were patients here. They deeply appreciate the level of care they received, so they want to give back as a way of showing their gratitude. Others simply enjoy taking care of people and making a difference. We also have volunteers who are interested in pursuing healthcare careers and want to learn more about our environment. Please tell us in 250 words or more why you would like to be a volunteer at Sibley Memorial Hospital.