VS Pre-Assigned Volunteer Application

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PRE-ASSIGNED VOLUNTEER APPLICATION

If you will be working with patients or in a patient care setting, you must be available for an in-person health screening in Ann Arbor on the date of your choice during the next six weeks. If you are not able to do so, please stop now. Your application will not be accepted. Please apply later when you are able to attend an in-person health screening.

Required Fields are marked with an asterisk (*)

Volunteer Information

* First Name (Legal)

M.I.

* Last Name (Legal)

Preferred Name

UMID Number (If known, this could expedite your application.)

* Local Address

Apt #

* City

State

* Zip/Postal

* Permanent Address

Apt #

* City

State

Zip/postal

Country

* Phone- Cell (XXX)XXX-XXXX

Alternate Phone if no cell (XXX)XXX-XXXX

Sex

* Date of Birth (MM/DD/YYYY)

*Is Applicant a Minor? If yes, stop here. You must be at least 18 years of age to apply.

Which describes you best? 'College' includes graduate and undergraduate students.

Which of these best describes your connection to the University of Michigan? If two or more apply, choose the one you feel defines your role at U of M best.

If you are a Michigan Medicine (not University of Michigan campus) employee or learner, please upload a photo of your employee ID badge.

Citizenship and Visa Information

Citizenship

Check if you are in the U.S. on a Visa

Visa Type (Please select)

Visa - other

Visa Exp. Date

NOTE: Please upload a copy of your visa with at least one form of supporting documentation.

Visa (Upload image)

Visa Supporting Documentation such as I 20, I 94, or DS 2019 forms.

Emergency Contact Information

* Emergency Contact Name First/last (Local)

* Relationship

* Primary Phone Number (XXX)XXX-XXXX

* Emergency Contact Name First/Last (Family)

* Relationship

* Primary Phone Number (XXX)XXX-XXXX

Criminal Records Check Information

Have you ever been convicted of a misdemeanor or a felony?

Are there any felony charges pending against you?

Is there anything in your history you want to tell us before we run your criminal background check? If yes, please describe below.

Placement Information

* Department

* Department Head

* Pre-Assigned Placement

* Department Campus Address

* Department Phone (XXX)XXX-XXXX

* Primary Pre-Assigned Supervisor Name - list only one name

* Pre-Assigned Supervisor Email - list only one email

* Pre-Assigned Supervisor Telephone

* Volunteer's Work Location (Building and Room)

* *Description of Volunteer Duties (Please be specific ESPECIALLY about patient contact)

*Will you work with with patients, blood, other? NOTE: Work with Patients means 'in the room' with Patients/Families/Visitors/Study Participants.

Are you available to attend an in-person health screening in Ann Arbor on the date of your choice during the next six weeks?

If you are not available for a health screening, please stop now. Your application will not be accepted. Please apply later when you are able to attend an in-person health screening.

Lab/Research/Med Student/Intern/Practicum (Click all that apply)

If this is a Practicum/Internship/Preceptorship, will you be receiving course credit, monetary or other compensation for this placement?

Proposed Schedule

* PA Appointment Start Date

* PA Appointment End Date

Note: Maximum 1 year (Annual Update required if extending past 1 year)

* Scheduled Weekday(s), Time(s)

Note: Minimum 40 hrs or 90 days, whichever comes first

Have you been approved for the HOPE Ambassador program? If so, the Office of Patient Experience has additional questions for you.

Volunteer Referral Source

Gender Identity

Gender Not Listed

Personal Pronoun

Personal Pronoun Not Listed

Sexual Orientation

Sexual Orientation Not Listed

Languages Spoken

Primary Language

Additional languages (please select all that apply)

References

Please give three character references (they could be work, academic, or personal) who can respond to our inquiry about you.

Reference #1

* Reference Full Name

* Reference Email

* Reference Phone

Reference #2

* Reference Full Name

* Reference Email

* Reference Phone

Reference #3

* Reference Full Name

* Reference Email

* Reference Phone

Certification

I certify that my answers are true and complete to the best of my knowledge. I agree that this information has been verified and references may be contacted by Michigan Medicine Volunteer Services.

I, the undersigned, authorize the University of Michigan, on behalf of Michigan Medicine, to conduct a criminal history check and review of the Federal Exclusion Lists. These checks will be performed to evaluate whether I am qualified to volunteer at the University of Michigan.
I understand that Michigan Medicine will contract with an outside vendor to conduct these investigations utilizing names and identifiers to determine the existence of any arrest resulting in conviction and furnish a response to Michigan Medicine.
I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for volunteering will not be processed further.
Misrepresentation of facts constitutes cause for separation from Volunteer Services.

* (check box for agreement)

* Type Your Full Name

* Date: (XX/XX/XXXX)

NOTE: This application expires in 30 days. If the volunteer applicant does not respond to required onboarding actions, the application must be resubmitted to Volunteer Services.