Special Placement Volunteer (SPV) On-boarding process Patient Contact Steps:

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Special Placement Volunteer (SPV) On-boarding process Patient Contact Steps: Request to Appoint a Special Placement Volunteer Form is completed and submitted to Office of Volunteer Services (OVP) OVP sends Application link via email to SPV applicant Criminal Background check submitted online (link sent with application) Medical Clearance- you will need a full medical clearance. Please print and complete all 3 forms attached and follow checklist. 1) Report of Medical Examination form (needs to be filled out by your Physician) 2) Medical History form 3) Allergy form Please contact: Upstate Employee Health Office- 2 nd floor of Jacobsen Hall Ph#315-464-4260, to schedule an appointment for your initial medical clearance. You will need to bring all completed health forms Flu Vaccination is mandatory due to the hospital being under State Mandate You will need proof of Flu Vaccination or plan to receive the vaccination during state mandate. All volunteers must be vaccinated to be permitted on Upstate campus. Flu vaccinations are available at the Upstate Employee Health Office when you go for you initial medical clearance Applicant completes all Training and Orientation requirements below: Follow this link: http://www.upstate.edu/hr/new_staff/orientation/non_employee_orientation.php ONLY COMPLETE #1 Non-Employee Orientation Guide and Completion Certificate #2 - HIPAA Privacy Rule Education and Completion certificate Print completion certificates and bring with you to the Office of Volunteer Programs (OVP) CITI TRAINING: Please check with your requestor to see what course(s) are required for your type of research. Payroll for ID badge: you will be issued a Special Placement Volunteer ID Badge after you have completed medical clearance. Please report to Payroll Services the 1 st floor of Jacobsen hall to obtain your Upstate Volunteer SPV ID Badge. After you have picked up your ID badge please go back to Upstate Employee Health Office, 4 th fl of Jacobsen Hall, to have a flu vaccination sticker placed on badge. ONCE YOU HAVE COMPLETED ALL STEPS: Please contact Lauren Saldo to set up an appointment to come in to OVP to sign paperwork Email: saldol@upstate.edu or Ph# 315-464-5177 Office of Volunteer Programs is located on the 1 st floor of the main hospital, ROOM 1401-stop at the information desk in the main lobby to ask for directions back to the office

Special Placement Volunteer Checklist Medical Clearance Checklist Task complete YOUR TASK 1. Complete the medical forms Information 1) Report of Medical Examination form (needs to be filled out by your Physician) 2) Medical History form 3) Allergy form 2. Make an appointment with the Health Office for your Initial Medical Clearance. Tell them you are a volunteer a. 1 st visit (any day but Thursdays) b. Return 48-72 hours later to have your arm read Make an appointment to get your 2nd PPD c. 2 nd Visit (any day but Thursdays) d. Return 48-72 hours later to have your arm read Location: 4th floor of Jacobsen Hall Phone number: 315-464-4260 Hours: 7:30 am 5 pm, Mon - Fri Bring with you: The three medical forms completed & signed* Copies of MMR records or titers (if available) You will receive a PPD shot (TB test) No appointment necessary 2nd PPD shot one week after your 1st reading (No appt necc) No appointment necessary Your Medical Clearance is now complete * If you do not have a primary care physician, please let us know, as the process will vary slightly. ALWAYS MAKE NOTE OF THE PERSON YOU ARE SPEAKING/WORKING WITH AT THE HEALTH OFFICE

Report of Medical Examination Employee Student Health Service 750 East Adams Street Syracuse, New York 13210 Name: Dept./Program: Date of Exam: CLINICAL EVALUATION: CHECK EACH ITEM IN THE APPROPRIATE COLUMN; NE IS NOT EVALUATED Normal Abnormal NE Notes: Describe abnormality with pertinent numeral before comment. 1. General Appearance 2. Skin 3. Head 4. Eyes 5. Ophthalmoscopic 6. Ears 7. Nose 8. Mouth/throat 9. Neck/thyroid 10. Lymphatics 11. Breasts 12. Thorax/lungs 13. Heart 14. Abdomen 15. Vascular system 16. Extremities/feet 17. Spine 18. Musculoskeletal 19. Neurologic 20. Psychiatric Height: Weight: Temperature: Blood Pressure: Systolic: Diastolic: Pulse: Gross Hearing: R: L: Corrected Vision: R: L: Diagnosis and assessment of medical problems: No Medical Problems Ongoing medical problems: (Explain) Limitations/Recommendations: (Further specialist examinations, labwork, x-ray, immunizations, etc.) No Limitations Limitations: (Explain) Health Care Provider (print): Health Care Provider (signature): Address: Telephone No.: ( ) (continue on back if necessary) STATE AND LICENSE # F82055 Rev. 3/2013

Medical History Form EMPLOYEE/STUDENT HEALTH Jacobsen Hall 750 East Adams Street Syracuse, NY 13210 315-464-4260 (telephone) 315-464-5471 (fax) www.upstate.edu Last Name First MI Sex Date of Birth Social Security Number Local Address (No. and Street) City State Zip Telephone Number Place of Birth Job Title Department or Unit Supervisor Dept/Unit Phone Emergency Contact Telephone Personal Medical Provider Telephone Personal Health History Have you EVER HAD, or do you have, any of the following? Check EACH item. If yes, specify by number and explain: No Yes 1. Chicken pox or shingles... 2. Measles... 3. Mumps... 4. Skin problems or chronic rash... 5. Eye problems... 6. Hearing loss or ear problems... 7. Chronic cough... 8. Asthma... 9. Shortness of breath... 10. Lung problems... 11. Tuberculosis or positive TB skin test... 12. Chest pain... 13. Heart trouble/attack... 14. Palpitations/irregular heart beat... 15. Heart murmur... 16. High blood pressure... 17. Stroke or paralysis... 18. Stomach or intestinal problem... 19. Liver disease/hepatitis... 20. Kidney disease... 21. Weight change... 22. Thyroid problems... 23. Shoulder/elbow/wrist/hand pain... 24. Numbness/tingling of arms or hands... No Yes 25. Broken bones... 26. Bone or joint problems... 27. Arthritis/gout... 28. Back pain/injury... 29. Numbness/tingling legs or feet... 30. Knee pain/injury... 31. Foot pain/injury... 32. Neck pain/injury... 33. Loss of limb... 34. Severe headaches... 35. Dizziness or fainting... 36. Epilepsy or seizures... 37. Severe weakness or tiredness... 38. Depression or anxiety... 39. Emotional or psychiatric problems... 40. Drug or Alcohol dependency... 41. Eating disorder... 42. Bleeding or blood disorder... 43. Immune suppression... 44. Chronic/recurrent infection... 45. Tumor/cancer... 46. Anemia... 47. Diabetic... 48. Any other illness not listed... Continues on next page F82010 Rev. 12/2014

Habits and Questions Related to Work Please Check Each Item, If YES, specify by number and explain: No Yes 1. Do you take medications (list all below)... 2. Do you have any allergies to medication... 3. Do you use other drugs that are not legal... 4. Do you use alcohol... 5. Refused as a blood donor... 6. Do you smoke cigarettes... 7. Have you ever been hospitalized... 8. Have you ever had surgery... 9. Have you ever received treatment or counseling for psychiatric or emotional illness... 10. Do you have allergies to certain chemicals, dust, animals, or animal products (animal dander, bedding waste)... 11. Have you ever been refused employment for health reasons... No Yes 12. Do you have visual, hearing or other physical limitations... 13. Is there any inability to move or position your body in a normal way... 14. Is there any reason you cannot fully perform all duties that your employment or volunteer work will require on any shift... 15. Have you ever had a work related injury or illness... 16. Are you currently working (if so, what job).. 17. Have you ever had: a) needlestick/blood or body fluid exposure... b) rash or symptoms related to glove use... List physicians or other health care providers you have seen in the past three years: I understand that any offer of employment is contingent upon my ability to perform, with reasonable accommodation if necessary, the duties for the position based on medical examination and any other information necessary to determine medical clearance for employment. Such examination is consistent with business necessity and requires that determination be made that you do not pose a risk to patients, co-workers or others individuals in the workplace. I certify that the information documented on this form is true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts may prevent my employment or may be cause for termination after beginning employment. Name (Print) Name (Signed) Date Comments by Clinician: F82010 Rev. 12/2014

Employee/Student Health 750 East Adams Street Syracuse, NY 13210 Phone: 315.464.4260 Fax: 315.464.5471 ALLERGY HX SCREENING Name: Department: ID#: 1. Do you have allergies? l Yes l No 2. Detail allergies: 3. Do you have a history of... contact dermatitis....l Yes l No eczema.... l Yes l No rhinitis or conjunctivitis...l Yes l No hay fever....l Yes l No asthma... l Yes l No autoimmune disease...l Yes l No 4. Do you have any food allergies? l NONE Check any of the following if positive: l banana l fig l peaches l avocado l nectarine l tomato l papaya l plum l potato l kiwi l cherry l chestnuts l passion fruit l melons l milk 5. Have you ever had an allergic reaction to latex products? l NO If yes, check all that apply: l adhesive tape l baby bottle nipples l balloons l ACE bandages l band-aids l dental cofferdams l belts, bras, suspenders l dental masks l carpet backing l erasers l cuffs, elastic waistbands l face masks l foam rubber l garden hose l hot water bottles l IV tubing l latex birth control devices l ostomy bags l rubber bands, balls l rubber cement l rubber gloves l rubber tennis/golf grips l pacifiers, teething rings l weather stripping other: 6. After handling latex products, have you experienced... Check all that apply: l redness l dermatitis l hives l itching (hands, eyes, etc.) l swelling l runny nose/congestion l problem breathing other: 7. History of latex reactions or undiagnosed reactions during medical or dental work..... l Yes l No Describe response: 8. Does your occupation involve exposure to latex or rubber?.... l Yes l No If yes, what latex products do you work with? 9. Will this employment involve direct or indirect contact with animals or animal products?... l Yes l No If yes, Animal Contact Form must be completed. 10. Comments and Recommendations: Your Signature: Date: ESH Staff Initials: F82046 Rev. 6/2015

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