Volunteer Packet Revised July 2014

8/11/2019 Volunteer Packet Revised July 2014

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completing &tep 35 +efer to &upplement 3 for information on how to complete the training5hen finished, print out the certificates and return to Deb to -eep in your file5

Step 5: During your orientation, you will receie final details about olunteering, training,and a uniform5 e will also wor- with you to schedule the days and times on which youolunteer so that they are conenient for you5 Orientation should ta-e no longer than acouple of hours we would li-e to do a tour of our beautiful facility and introduce you to asmany of our caregiers as possible if you hae the time5

*Please notify Deb Olson when you complete steps in the process. We are very excited tohave you become a member of our family here at the Stephenson Cancer Center.

Volunteers brin so much to the patient experience! and we than" you for ma"in a place

in your heart and in your life for our patients#


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Volunteer Information Sheet

Date: ________________

Mr./Mrs./Ms.____________________________________________________________________

(first) (middle) (last)

Present Address: _______________________________________________________________

(street)

_________________________________________________________________________(city) (state) (zip)

Cell Phone: _______________________ Home Phone: __________________________

E-mail Address: ____________________________________________________________

Date of Birth: ___________________

Name of Spouse: ______________________ Cell Phone: _____________________________

Have you had previous volunteer experience? [ ] Yes [ ] No

If yes, name of organization: _____________________________________________________

From ______________to________________

Are you currently a student? [ ] Yes [ ] No Where? ______________________________

Special skills and interests: _______________________________________________

Computer literate? [ ] Yes [ ] No Foreign languages: _______________________

Reason for wanting to volunteer: ___________________________________________

Name of physician: ______________________________________________________

Form 1


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City, State and Phone number: __________________________________________________

Limitations related to health? ___________________________________________________

Are you allergic to any drugs? [ ] Yes [ ] No If so, what? _____________________

If case of emergency, contact: ________________________Relationship: _______________

Address: ________________________________________________________________________

(street) (city) (state) (zip)

Cell Phone: __________________________Home Phone: ____________________________

I agree to and have signed the Volunteer Waiver and Release of Liability Form.

Signature of Applicant: _____________________________________ Date: ______________

If you have any questions, please contact:

PLEASE RETURN TO:

Stepenson .ancer .enter Volunteer Ser/ices+ttn: eb !lson 00 3$$ 10tStreet' "m &050 !laoma .it6' !# 7%104

Telephone: (405) 271-8384 Fax: (405) 271-5797Attention: Deb Olson

Opportunities for volunteers are provided without regard to race, color, national origin,

sex, age, religion, political affiliation, disability, or veteran status.


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Form 2


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ni/ersit6 o8 !laoma ealt Sciences .enter .ampus+V" and "9+S o8 9+B9T

Tis ai/er and "elease o8 9iabilit6 (;+,reementuries orlosses 6ou ma6 cause or sustain as a result o8 6our decision to per8orm' =itoutcompensation /olunteer tass (;Ser/ices


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"elease 8rom 9iabilit6' ndemni8ication +,reementand .o/enant 3ot to Sue

0o the fullest etent permitted by law, on behalf of myself, my spouse, heir, representaties, eecutors, administrators andassigns, # agree to foreer +("(@&(, #*D(*#F


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3V"ST ?*9! +9T S"V.S

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA*atient 3ame (*lease print)

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAVolunteerAAAAAAAAAAAAAAAate o8 Birt +,e T6pe o8 ob

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAome +ddress .it6 State Cip .ode

(AAAA)AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA( )AAAAAAAAAAAA AAome *one

or *one

SA? A ? F AA

?arital Status "ace SeD

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA (AAA)AAAAAAAAAAAAAAAAAAAmer,enc6 .ontact *erson "elationsip Telepone

Aebora !lsonAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAA(405)271-%4AAA?ana,erEs name Telepone

A*atient Ser/icesAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAStepenson .ancer .enterepartment.linic name 9ocation

0his is to certify that #, the undersigned, consent to the performance of procedures deemed necessary in the opinion ofthe attending physician5 # reBuest and authori?e 'niersity (mployee )ealth &erices to hae access to the informationand medical documentation relating to my isits at 'niersity (mployee )ealth &erices5

I hereby authorize University Employee Health Services to release all or any portion of my records, including x-rays and laboratory

results regarding my diagnosis, care and treatment rendered by University Employee Health Services. his authorization includes, but

is not limited to, my employer, insurance companies and !or"ers# compensation carriers.

AAAAAAAA

Form #5

Form 5a


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*atient Si,nature ate


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*+ST ST!": (a/e 6ou e/er ad an6 o8 te 8ollo=in, conditionsG)

AA+nemia AA.arpal Tunnel AAearin, loss AA9un, in8ectionsAA+n,ina pectoris AA.olitis AAeart isease AA?i,rainesAA+rtritis AA.olor Blindness AAepatitis AA3er/ous Breado=nAA+stma AAiabetes AAi, blood pressure AA*rior =or in>ur6AABac strain AAmp6sema AAi/es AA"uptured discAABleedin, trouble AA@out AAaundice AASeiHuresAA.ancer AAa6 8e/er AA#idne6 disease AASmoin,

*"S!3+9 +BTS:

.ircle i8 6ou e/er smoed: .i,arettes *ipe .i,ars

3umber per da6:AAAAAAAAAAA o= man6 6ears did 6ou smoe:AAAAAAAAAAAA

+re 6ou currentl6 a smoer: es 3o

+99"@S:

S"!S 3"S: (9ist and ,i/e approDimate dates)

!S*T+9 ST+S-!"-!*"+T!3S: (9ist and ,i/e approDimate dates)

?.+T!3S: (.ec all 6ou are currentl6 tain,)

AA+stma=eeHin, medicine AAormonesBirt control pillsAAStomaculcer medicine AAnsuliniabetic pillsAA+spirinT6lenol+d/il3uprin AA+ntibioticsAABlood tinners AASeiHure medicineAABlood pressure pills AA6e dropsAA.ou, medicine AAT6roid medicineAA.ortisone*rednisone AAVitaminsAAi,italiseart medicine AAei,t reducin, pillsAASleepin, pillstranIuiliHers AAater pillsdiureticsAA.olesterol reducin, medicine

Form 5b


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o!thbo!n" #he$e % 77 (&$oa"#a' xtension) beo*es +-235:

Take the Oklahoma Health Center/University of Oklahoma Health Sciences Center Exit

1! to "E 1$thStreet

T%rn left on "E 1$th Street

T%rn ri&ht at the 'e&&y ( Charles Ste)henson Cancer Center

*alet assistance an+ )arkin& &ara&e is strai&ht ahea+

,estbo!n" +-44

Supplement 1TB Test andVaccinations

Supplement 2

How to find the Volunteer office:

Enter through the Peggy & Charles Stephenson Cancer Center

parking garage located at 800 NE 10thStreet.

Pull up to the gates and the gate will open automatically.

Park on the 1, 2, or 3 floor and enter the building from the parking

garage.

Please notify the greeter at the front desk on the first floor (not LL)

Form 6Peggy & Charles

Stephenson Cancer

Center and adjacent

parking garage


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,estbo!n" on +-40 :

Exit at the Oklahoma Health Center Exit 139 onto ,375

Take the University of Oklahoma Health Sciences Center Exit 16 secon+

exit on the ri&ht; .hich ecomes 0incoln o%levar+

Contin%e north to "E 1$th Street

T%rn ri&ht on "E 1$th Street



.i/h#a' 3 ast onnetin/ to +-44 eastbo!n":

From ,-- take roa+.ay Extension so%th2 .hich ecomes ,375

Take the Oklahoma Health Center/University of Oklahoma Health Sciences CenterExit 1!

T%rn left on "E 1$th Street



Supplement 2


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!o to the .esite:htt)://...o%hsce+%/hi))a/

to com)lete the H,' trainin&

Call or Email 6e Olsonto otain yo%r Trainee ,6

3o%hsce+%

Supplement 3
mailto:[email protected]:[email protected]

Documents

Volunteer Packet Revised July 2014