VOLUNTEER SERVICES APPLICATION
NOTE: All Volunteers will be required to submit an application, participate in a face-to-face interview, provide references for
checking, complete a background check, health screening, attend an orientation, and complete a training program prior to
placement. Applicants who provide false information or have a negative background check may be disqualified for, or
terminated from, service.
Completed application and references must be submitted together in one packet. Please return the completed packet to the
program coordinator in your area of interest. A completed application includes 1) application form 2) references
3) background check form and 4) blue “Volunteer Clearance form” from Employee Health or Student Health. Please do not
submit any medical records with your application. We are unable to accept incomplete applications.
To obtain information regarding the available programs and opportunities for volunteering at Duke, please visit our website
at: http://www.dukehealth.org/patients_and_visitors/volunteer_services/volunteering_at_duke
Name: ___________________________________________________________________________________
(Last)
(First)
(Middle)
Maiden Name or Alias(es) ______________________Home Phone____________ Cell Phone ____________
Current Address: __________________________________________________________________________
(Street)
__________________________________________________________________________
(City)
(State)
(Zip)
(County)
Student: Home Address _____________________________________________________________________________________
(City)
(State)
(Zip)
Email address: ____________________________________________________________________________
Are you at least 18 years of age? __________
Last 4 Digits of SS# __________________
(If NO, you must apply through the Junior Volunteer process.
Please see our website for specific information regarding this program.)
How did you hear about our Volunteer Program? (please provide the name of the resource you used to learn about our programs )
Friend ___________Organization___________ Newsletter_________ Internet ___________Other__________
Emergency Contact Person: __________________________________________ Relationship: ___________________
Home Number: ____________________ Work Number: ___________________ Cell Number: ____________________
EMPLOYMENT:
If applicable, please list your current employer’s name and address below.
_________________________________________________________________________________________________
How long have you been with this employer? ___________
May we contact you at work? Yes
No
N/A
If yes, Please provide your work phone _____________________
Are you presently enrolled at a school or university? If yes, list school and graduation year.
_______________________________________________________________________________________
What is your current area of study? _________________________________________________
EXPERIENCE/SKILLS:
Have you had previous volunteer experience? _____ Are you involved in other community service organization? _____
(Churches, Clubs, Organizations, etc.)
If so, please provide the following information for each volunteer experience/organization:
Volunteer Experience/Service Organization
Program Supervisors & Contact Info
________________________________________
_________________________________
________________________________________
_________________________________
________________________________________
_________________________________
________________________________________
_________________________________
Dates of Service
_____________
_____________
_____________
_____________
Are you currently an active member of the Retired Seniors Volunteer Program? _____ If Yes, when did you join?_______
Please list any professional or healthcare related license(s) or certification(s) that you feel would enable us to better match
you with a Volunteer program? (i.e. CPR certification)
____________________________________________________________________________________________________________
Please list any educational, personal, or professional experience that you would like us to consider when matching you to
a particular Volunteer program:
__________________________________________________________________________________________________
Can you speak fluently, read or write a language other than English? ____________
If yes, Please list the Languages Below:
Language____________________________________________
Language____________________________________________
Speaks Fluently ________
Speaks Fluently ________
Read/Write_________
Read/Write_________
What is the one skill or skills that you are proficient at that you would gladly share with us if we could make it possible
for you to do so and if it syncs for us strategically?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERESTS:
What are your leisure time activities?
__________________________________________________________________________________________________
What influenced your decision to volunteer at Duke University Medical Center?
__________________________________________________________________________________________________
Please list the Duke volunteer program(s) you are most interested in.
__________________________________________________________________________________________________
AVAILABILITY:
Days and Hours available to volunteer:
Monday
Friday
8:30 AM-12:30 PM
Tuesday
Saturday
12 NOON- 4:00PM
Wednesday
Sunday
Other _____________________________
Thursday
(Please note if evenings and/or weekends are the best times to volunteer)
REFERENCE/CRIMINAL CHECK:
REFERENCES:
Name
E-mail Address/Phone Number
Relationship
1. ____________________________________________________________________________________________
2. ____________________________________________________________________________________________
Additional forms are included in this packet for your references. Please submit completed references with the application
form. The entire packet needs to be submitted together as we are unable to accept incomplete applications.
Background:
Have you ever been convicted of a crime other than a minor traffic offense? ______________________________
If Yes, when, where, and nature of offense, disposition:_____________________________________________
Note: ALL volunteer positions at Duke University Medical Center require a Court Record Release/Background Check
Volunteer Services Agreement
In connection with my activities as a volunteer I agree to hold confidential all information to which I may have access. This includes,
but is not limited to, information on current, former, or prospective patients, employees, students, and scholars. Disclosure of such
information to unauthorized persons is prohibited and may result in my dismissal from the volunteer program and may have
additional legal consequences.
I am aware that Duke Medicine does not provide insurance coverage for volunteers if personally injured or if damage occurs to
personal property while acting as a volunteer. I further understand that I am not entitled to worker’s compensation benefits, health
insurance benefits, or any other benefit available to employees of Duke University. I agree that I will not hold Duke Medicine or its
officers or agents thereof liable for any injury sustained to person or property while acting in a volunteer capacity.
The information provided in this application for volunteering is true, correct and complete. If accepted as a volunteer, any
misstatement or omission of fact on this application may result in my ineligibility for volunteering, or if accepted as a volunteer may
result in my dismissal. I hereby authorize Duke University Hospital to determine my suitability and justification for my role as a
volunteer, to contact any or all of my references.
I authorize schools, employers and references named in this application to provide Duke University Hospital with any relevant
information that may be required to arrive at a decision regarding being accepted as a volunteer. In connections therewith and in
consideration of the undertaking of Duke University Hospital to review this application for volunteering and to consider me for a
volunteer position, I hereby release and acquit Duke University Hospital from any liability whatsoever for any damage which I may
suffer or sustain by reason of its use of any such information.
I understand that should I be offered a volunteer position, I am required to have a volunteer health screen prior to beginning work. The
volunteer health screen is provided by the hospital and includes drug testing. I realize that Duke University Hospital does background
checks when considering applicants for positions and that I will be requested to complete a background check form which requires
date of birth and social security number to facilitate the background check.
I have completed the above information to the best of my ability and understand that any falsification of the information provided
above may disqualify me to become a volunteer.
_______________________________________________________________
Applicant Signature
_________________
Date
For Office Use Only:
DUKE CONFIDENTIALITY AGREEMENT
I agree to protect the confidentiality, privacy and security of patient, student, personnel, business and other confidential, sensitive
electronic or proprietary information (collectively, “Confidential Information”) of Duke University, Duke University Health System
and the Private Diagnostic Clinic (collectively, “Duke”) from any source and in any form (talking, paper, electronic). I understand
that the kinds of Confidential Information that I may see or hear on my job and must protect include the following, among others:





PATIENTS AND/OR FAMILY MEMBERS (such as patient records, conversations and billing information)
MEDICAL STAFF, EMPLOYEES, VOLUNTEERS, STUDENTS, or CONTRACTORS (such as social security
numbers, evaluations, salaries, other clinical information, employment records, disciplinary actions)
BUSINESS INFORMATION (such as financial records, research or clinical trial data, reports, contracts, computer
programs, technology)
THIRD PARTIES (such as vendor contracts, computer programs, technology)
OPERATIONS, PERFORMANCE IMPROVEMENT, QUALITY ASSURANCE, MEDICAL OR PEER REVIEW
(such as utilization, data reports, quality improvement, presentations, survey results)
I AGREE THAT:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
I WILL protect Duke Confidential Information in any form. I WILL follow Duke policies, procedures and other privacy and security
requirements.
I WILL NOT post or discuss any Duke Confidential Information, including patient information, patient pictures or videos, Duke
financial or personnel information on my personal social media sites such as Facebook or Twitter. I WILL NOT take any pictures of
patients for personal use with my cell phone or similar methods. I WILL NOT post Confidential Information including patient
pictures on Duke-sponsored social media sites without the appropriate patient authorization in accordance with management approval
and Duke policies and procedures.
I WILL complete all required privacy and security of Confidential Information training.
I WILL ONLY access information that I need for my job or service at Duke.
I WILL NOT access, show, tell, use, release, e-mail, copy, give, sell, review, change or dispose of Confidential Information unless it
is part of my job or to provide service at Duke. If it is part of my job or to provide service to do any of these tasks, I will follow the
correct procedures (such as shredding confidential papers using confidential, Shred-it™ lock bins lock bins) and only access/use the
minimum necessary of the information to complete the required task.
When my work or service at Duke ends, I will not disclose any Confidential Information, and I will not take any Confidential
Information with me if I leave or am terminated.
If I must take Confidential Information off Duke property, I will do so only with my supervisor’s permission and in accordance with
Duke policies and procedures. I will protect the privacy and security of the information in accordance with Duke policies and
procedures, and I will return it to Duke.
If I have access to Duke computer system(s), I WILL follow their Secure System Usage Memos, which are available from the
System’s Information Security Administrator(s).
I WILL NOT use another’s User ID (Net ID) and password to access any Duke system, and I will not share my User ID (Net ID)
password or other computer password with anyone.
I WILL create a strong password* and change it in accordance with Duke policies and procedures. I will notify DHTS Security Office
and change my password at once if I think someone knows or used my password. I will ask my supervisor if I do not know how to
change my password.
I WILL tell my supervisor and OIT or DHTS if I think someone knows or may use my password or if I am aware of any possible
breaches of confidentiality at Duke.
I WILL log out or secure my workstation when I leave the computer unattended.
I WILL ONLY access Confidential Information at remote locations with consent from my supervisor.
If I am allowed to remotely access Confidential Information, I AM RESPONSIBLE for ensuring the privacy and security of the
information at ANY location (e.g., home, office, etc.).
I WILL NOT store Confidential Information on non-Duke systems including on personal computers/devices.
I WILL NOT maintain or send Confidential Information to any unencrypted mobile device in accordance with Duke policies
and procedures.
I UNDERSTAND that my access to Confidential Information and my Duke e-mail account may be audited.
If I receive personal information through Duke e-mail or other Duke systems, I AGREE that authorized Duke personnel may examine
it, and I do not expect it to be protected by Duke.
I UNDERSTAND that Duke may take away or limit my access at any time.
I understand that my failure to comply with this Agreement may result in the termination of my relationship with Duke and/or
civil or criminal legal penalties. By signing this, I agree that I have read, understand and will comply with this Agreement.
Signature
Date
Print Full Name
Dept.
Rev. 9/2011
Examples of Breach of Confidentiality
(What you should NOT do)
These are examples only. They do not include all possible breaches of confidentiality covered by the Duke Breach of PHI or Breach
of Confidential Information policies and this Confidentiality Agreement.
Accessing information that you do not need to know to do
your job:
• Unauthorized reading of patient account information.
• Unauthorized reading of a patient’s chart.
• Accessing information on adult children, friends, or coworkers.
Sharing, copying or changing information without proper
authorization:
• Making unauthorized marks on a patient’s chart.
• Making unauthorized changes to an employee file.
• Discussing Confidential Information in a public area such
as a waiting room, elevator or cafeteria.
• Posting a picture of a patient on Facebook.
• Discussing the status of a patient’s health with others on
Facebook
• E-mailing friends to inform them about how a patient is
doing
Leaving patient log books open that contain patient
information
Sharing your User ID and password:
• Telling someone your password so that he or she can log
in to your work.
• Giving someone the access codes for employee files or
patient accounts.
• Emailing Confidential Information outside of Duke by
unsecure methods (not encrypted)
Leaving a secured application** unattended while signed
on:
• Being away from your computer while you are logged
into an application.
• Allowing someone to access Confidential Information
using your User ID (NET ID) and password.
DEFINITIONS
**Secured Application – any computer program that allows access to Confidential Information. A secured application usually
requires a user name and password to log in.
*Strong Computer Passwords are defined in the DHE Information Security Standard: Passwords and must be in accordance
with Duke IT security policies.
3-D Background Screening for Duke University Health System
NOTE: ALL FIELDS MUST BE COMPLETED or application will not be processed.
*Are you a current Duke employee with an employment status that can be verified through Duke HR?
__________
*First Name: ________________________________________________
*Full Middle Name: __________________________________________
*Last Name: ________________________________________________
*Contact Phone: ______________________________________________
*Email: _____________________________________________________
*Social Security Number: ______-______-______
*Date of Birth: _____/______/_______
*County Volunteer is currently living in: _________________
If you do not know the following information, please do NOT submit this form until you have been interviewed and
placed, as it will delay your Volunteer service at Duke.
*Volunteer Program: ______________________________________________________________________
*Volunteer Coordinator & Contact Information: ________________________________________________
Signing this form gives Duke Medicine Volunteer Services express permission to check any and all background databases
regarding applicant.
*Signature of volunteer: _______________________________
Date: _______________________
To be returned with completed Application
DUKE MEDICINE
Volunteer Services
Request for References
*Applicant: Please fill out your name and volunteer program.
____________________________________________ has applied to be a volunteer with the
(Applicant Name)
______________________________________________________________________ Volunteer Program.
(Volunteer Program)
Please respond to the following questions with care and be as complete as possible.
1.
In what capacity have you known the Volunteer applicant, and for how long?
2.
Briefly, how would you describe the applicant?
3.
What strengths do you believe the applicant will bring to this position as a volunteer?
4.
What do you think may be the applicant’s greatest challenge in volunteering here?
5.
We have very strict policies on confidentiality for our Volunteers, do you think the
applicant will be able to understand and follow these policies? Why or why not?
6.
On a scale of 1 to 5, 1 being Poor and 5 being Excellent, rate the applicant on the following:
Ability to work in a team
Use of conflict resolution skills
Flexibility
Dependability
Organizational Skills
7.
___
___
___
___
___
Ability to work independently
Ability to take direction
Communication
Honesty/Integrity
Multi-Tasking Skills
___
___
___
___
___
Would you have this applicant volunteer with your organization or business? Why or why not?
I VERIFY THE ABOVE INFORMATION TO BE CORRECT
_______________________________
________________________________
Printed Name
Signature
_________________________________________________________________________
E-Mail Address
________________
Date
_______________
Contact Phone
To be returned with completed Application
DUKE MEDICINE
Volunteer Services
Request for References
*Applicant: Please fill out your name and volunteer program.
____________________________________________ has applied to be a volunteer with the
(Applicant Name)
______________________________________________________________________ Volunteer Program.
(Volunteer Program)
Please respond to the following questions with care and be as complete as possible.
8.
In what capacity have you known the Volunteer applicant, and for how long?
9.
Briefly, how would you describe the applicant?
10.
What strengths do you believe the applicant will bring to this position as a volunteer?
11.
What do you think may be the applicant’s greatest challenge in volunteering here?
12.
We have very strict policies on confidentiality for our Volunteers, do you think the
applicant will be able to understand and follow these policies? Why or why not?
13.
On a scale of 1 to 5, 1 being Poor and 5 being Excellent, rate the applicant on the following:
Ability to work in a team
Use of conflict resolution skills
Flexibility
Dependability
Organizational Skills
14.
___
___
___
___
___
Ability to work independently
Ability to take direction
Communication
Honesty/Integrity
Multi-Tasking Skills
___
___
___
___
___
Would you have this applicant volunteer with your organization or business? Why or why not?
I VERIFY THE ABOVE INFORMATION TO BE CORRECT
_______________________________
________________________________
Printed Name
Signature
_________________________________________________________________________
E-Mail Address
________________
Date
_______________
Contact Phone
To be taken to Employee Health and Wellness Office
(Duke Students may take this form to the Student Health Office)
Volunteer – Health Review Sheet
NOTE: Please fill out this form and take it to your appointment with Employee Occupation Health and Wellness (EOHW)
to complete the required Health Review. You must submit this Health Review Sheet to the Employee Health office for
your TB test. * You will need to obtain a blue “Volunteer Clearance” form from Employee Health or Student
Health and provide this “volunteer clearance” form to your coordinator before you sign up for training and
Orientation with your assigned area.
Employee Occupational Health and Wellness
Located in Duke South (Outpatient Clinic Building), Ground Level, Red Zone, Room 04290
Hours: 7:30 am – 4:15 pm Monday – Friday, except Wednesday – closed 12:00 – 2:00 pm
Phone # 684-3136 – Please call this number to set up your appointment time
Name ______________________________________________________________________________________________________
Last
First
Middle
Female ______ Male ______
SS# ______________________________ Duke Unique ID# _______________________________
(Required)
Date of Birth _________________________
Age ______
Marital Status ______________________________________
Address _______________________________________________ ________________________ ___________ _____________
City
State
Zip
Home Phone _____________________ Work Phone ________________________ E-mail_________________________________
Volunteer Program ______________________________________ Volunteer Coordinator/Supervisor________________________
Are you a Duke University employee? Yes ____ No ____
*NOTE* It is important for all volunteers to be immune to chicken pox, polio, measles, mumps and rubella. Official
documentation of immunity to rubella is required of all volunteers. If you were born after 1/1/57, we must also have
official documentation of immunity to measles and mumps. If you do not have official documentation with you at the
time of your appointment, the nursing staff will perform a titer test (A vaccine titer is the measure, or level, of
antibodies in the blood stream) in order to determine your current immunity.
Suggested Sources for Obtaining Official Documentation of immunity to rubella, measles, and mumps include:
School records, previous employee health records, Health Department records, Military records or Obstetrician or Primary Care records.
Communicable Disease / Immunization History
This health review information is important in protecting the health and safety of Duke University Medical Center volunteers, patients, students
and visitors. The nursing staff at the Duke Employee Occupational Health and Wellness department will assist you, if needed, in completing the
section below. This information will not appear on any other medical record you may have at Duke Medicine.
Have you ever tested positive for TB? _____________
Have you ever had the following diseases?
1.
2.
3.
Chicken pox (varicella)
Mumps
Tuberculosis (TB)
___Yes ___No
___Yes ___No
___Yes ___No
4.
5.
Measles (old fashioned, red)
Rubella (German)
___Yes ___No
___Yes ___No
Have you ever had the following vaccines / tests? If yes, give date and results (if applicable).
1.
2.
3.
4.
Polio vaccine
BCG vaccine
TB skin test
Chest x-ray
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
Date/Results __________
Date/Results __________
Date/Results __________
Date/Results __________
5. Rubella vaccine ___Yes ___No Date/Results __________
6. Mumps vaccine ___Yes ___No Date/Results __________
7. Measles vaccine ___Yes ___No Date/Results __________
Do you now have or have you ever had a physical condition or health related illness that would prohibit you from working with
patients in a health care setting?
___Yes ___No
If yes, please explain. __________________________________________________________________________
TB test date ________________________________________________ EOHS Staff ________________________________________