What interests you in volunteering in a Hospital Setting?

Are you currently employed? Yes   No

Present Occupation:

Education or training:

Have you ever served as a volunteer? Yes   No

Please list experience as a volunteer and/or previous experience:

Relatives or Friends who volunteer or are Employed at LVH?:

Have you ever been convicted of a misdemeanor or felony since your 16th birthday? Yes    No
If yes, please explain:

Skills: (Check if you have skill)

Typing  Computer   Medical Terminology
Foreign Language, which?
Other:

Form of transportation:
Car  Bus  Other, please explain:

How were you referred to Lehigh Valley Hospital?

In case of an emergency, please notify:
   Phone:

Family Physician:
   Phone:

Personal References (no family please)
A request for reference form will be sent to those listed below. These must be returned before your interview is scheduled.
Name:

Address:

Phone:
 Years Known:

Name:

Address:

Phone:
 Years Known:

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Please tell us about any physical limitations which should be considered in your volunteer assignment?


Communicable disease and immunization history is extremely important. It is needed so that we can reduce the risk of communicable disease exposure to our patients, other healthcare workers and you.

Check the childhood illnesses you have had:
Mumps  Measles (Rubella)  Polio  Diptheria
Rheumatic Fever  German Measles  Chicken Pox
Other illnesses:

Check the immunizations you have had, and, if known, the date that you had them.

Immunized	Date
		Influenza ("flu")
		Pneumonia
		MMR/Measles/Mumps/German Measles
		Diphtheria/Pertussis and Tetanus (DPT)
		Hepatitis Vaccine
		TB Screening (PPD) Results: Select Result Negative Positive

Have you ever had Tuberculosis? Yes    No
If so, when?

It is strongly recommended that all volunteers in a healthcare setting receive the influenza vaccine annually. This is offered at no cost to volunteers.

Annual TB screening is required for all healthcare volunteers.