Harvard Hospital Volunteer Program

in conjunction with Cambridge Health Alliance

Dear Prospective Volunteer,

Welcome to the Harvard Hospital Volunteer Program! The Harvard Pre-Medical Society is dedicated to
facilitating volunteer opportunities at Cambridge Health Alliance for Harvard undergraduates. Furthermore,
we plan to coordinate unique events (ie. physician shadowing or community service days) throughout the year
in order to provide a fulfilling volunteer experience. This packet should contain everything you need to begin
your volunteer experience with the Cambridge Health Alliance.

Please follow this checklist carefully:

1. Read through the Program Guidelines to gain a better understanding of how the program works
and what each placement entails.
2. Fill out the HVP application fully. When indicating availability, remember to allot 3 consecutive
hours for your shift as well as to account for transportation to and from the hospital.
3. Look at the CHA website and indicate on the HVP application which positions interest you.
http://www.challiance.org/howyoucangive/volunteer/opportunities.shtml
4. Obtain a copy of your immunization records, which should be available at UHS. These forms
must be turned in by the day of your orientation at CHA, but preferably along with the rest of
your application. The Immunization Record should include documentation of the following:
a. Candidates will be required to provide proof of immunity to measles, mumps and
rubella and a verbal history of chickenpox.
b. Tetanus Vaccination within the last 10 years
c. PPD (Pure protein derivative) TB- (Tuberculosis screening) test within the last 12
months. If the TB test was positive, you MUST bring your chest x-ray report to the
appointment
d. A blood test for Hepatitis B immunity.
5. Fill out the attached CORI form.
6. Finally, the last sheet of this application has more information about CHA’s new Hand Hygiene
program, and we encourage motivated students to join this pilot program and to make a
difference in hospital communities. If you are interested, please indicate so on your application.

We are excited about the tremendous response that HVP has received from the student body and are looking
for dedicated volunteers to continue to be of service to the medical community. Unfortunately, while we
would love to find placements for everyone at the hospital, this just may not be possible. For this reason, we
ask that you only apply if you are truly serious about the commitment. Volunteer shifts average 3 hours and
we expect volunteers to commit 4-5 hours per week (including travel time) to this program.

Applications are due on May 1st, 2011 by midnight.

We hope that you will decide to join HVP for a volunteer experience that promises to be both meaningful
and rewarding in helping Boston’s diverse population in a medical setting. We look forward to reading your
applications!

Sincerely,

Caleb Yeung cmyeung@fas.harvard.edu

Jonathan D’Gama jdgama@college.harvard.edu
Co-Directors, Harvard Hospital Volunteer Program, Harvard Pre-Medical Society
 Harvard Hospital Volunteer Program
2011-2012 Program Guidelines
in conjunction with Cambridge Health Alliance
Basic Guidelines:
! All volunteers must commit to work at least 3 hours per week (excluding travel time) for a
total of 24 weeks, which normally spans the course of two academic semesters; or
volunteer over the summer for 8 weeks
! Volunteers will be required to complete a mid-semester/summer evaluation each term
! Upon conclusion of one’s volunteer responsibilities, each volunteer will be awarded a
Certificate of Completion only if at least 50 of the committed hours are completed.
! Both interest and dedication are essential for enjoying this volunteering experience.

Applying for the Program:

! Students must return the 2011-2012 HVP application along with the CHA application
materials to the following location by the indicated deadline:
Quincy A-12
! Please have your immunization records and CORI form attached to your
application.
! Due to the exceptionally large number of applicants, preferences will be given to past
volunteers with a strong record of commitment. We regretfully are not accepting
applications from freshman this year due to the limited number of volunteer openings.
! Availability during daytime shifts will usually have preference, as many people cannot
volunteer during this time, and demand for volunteers at the hospital is larger.
! Those accepted will be notified by e-mail and given the specifics about the mandatory
orientation at Cambridge Health Alliance while those not accepted are strongly
encouraged to reapply next year.

Please only apply if you intend on volunteering consistently for the duration of the
school year or during the summer.
 Harvard Hospital Volunteer Program
2010-2011 Application
Caleb Yeung, cmyeung@fas.harvard.edu
Jonathan D’Gama jdgama@college.harvard.edu
HVP Co-directors

Personal Information
Please enter all information

Name _______________________________________________________________
Last First Middle
Campus Address _______________________________________________________
Campus Phone ______________________ Cell Phone __________________________

E-mail Address ________________________________________ Class ____________

Hospital Placement
Please list in order your preferences for hospital departments

1. ____________________________________________________________
2. ____________________________________________________________
3. ____________________________________________________________
4. ____________________________________________________________
5. ________________________________________________________________________

Availability
Please check the time slots when you ARE available to volunteer, taking into account transportation to and from CHA (approx. 30-45 min each way)

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

9am

10am
11am

12pm
1pm
2pm
3pm
4pm

5pm
6pm
7pm

8pm
9pm
 Personal Questionnaire
Please answer the following questions thoroughly

1. What would you like us to know about you? (interests, extracurricular activities, etc.)

2. What do you hope to gain from your volunteer experience at CHA and why are you pursuing
this opportunity?

3. Should a change in your schedule arise, how are you prepared to maintain your commitment to
this volunteering experience?

Signature _____________________________________ Date ______________

Please return this application May 1st, 2011. This MUST be accompanied by the following CHA
application. Thank you for your time and interest.
 Volunteer Services Application

Which campus are you interested in: Cambridge ___ Somerville___Whidden___

In compliance with Federal and State Equal Employment Laws, qualified applicants are considered for all positions without regard to race, color,
religion , sex, national origin, age, marital status or the presence of a non-job related physical or mental handicap.

DATE: _____________________ PLEASE PRINT CLEARLY

NAME __________________________________________________________________________
Last First Middle Initial

ADDRESS _______________________________________________________________________
Street City State Zip

Phone_________________ Cell__________________ E-mail_______________________

Are you over the age of 18? Yes__No __. Parental consent is required for volunteers between the ages of 14 and 17.

Type of volunteer service preferred: ________________________________________

Days & Times Available__________________________________________________

===========================================================================
Education: Name of School Address Dates Graduate? Major Degree received
Attended
===========================================================================
High School
____________________________________________________________________________________
College
____________________________________________________________________________________
Technical School
____________________________________________________________________________________
Medical or
Nursing School

Employment experiences: List your most recent position first.

Company Address Dates Employed Position held Reason for Leaving

Volunteer Experience:
Where: Dates What was your assignment?

Cambridge Health Alliance Volunteer Services * 230 Highland Ave. Somerville, MA 02143
Personal References: Give names of 2 persons, other than relative & personal friends, who have known you for several
years. (E.g. rabbi, priest, minister, physician, teacher, counselor, employer)

Name Relationship Phone Number E-mail address

By whom were you referred to the Cambridge Health Alliance?________________________________________

Do you have any particular skills that would be helpful in a volunteer assignment? ______________

Do you speak any foreign language fluently or have knowledge of sign language? ______________

List any recreational activities or hobbies. __________________________________________________

In case of an emergency, whom do you wish us to notify?

Name: ____________________________
Relationship: __________________________________________
Telephone: _________________ 2nd number__________________
PLEASE READ CAREFULLLY AND SIGN THE STATEMENT BELOW

I certify that the information given above is true and complete and I understand that misrepresentation and/or withholding of information will result in a
rejection of this application or my discharge if discovered after volunteer service begins. I authorize the Alliance to make inquiries regarding my history and
character of prior employers, schools, etc. and hereby release employers, schools or individuals from all liability in responding to inquiries in connection with
my application and release the Alliance from all liability with respect to such inquiries.

I understand that if I am a volunteer I will be a volunteer at will and may terminate my volunteer assignment at any time with or without cause or notice and
that the Alliance also has that right. I also understand no representative of the Alliance, other than the CEO, has any authority to enter into any agreement for
volunteer service for any specified period of time or to make any agreement contrary to the foregoing and that such agreement must be in writing. As a
volunteer, I agree to abide by the Alliance’s policies, rules and procedures and any changes thereto.

I understand that I must provide to the Alliance an updated immunization record which includes verification of Tuberculosis test within the past year.

____________________________________________________________ ______________________________________
Applicant’s Signature Date

For Office Use Only

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Interviewer:

Comments:

Start Date: Department: Supervisor: Extension:

Schedule:

Drug Screen / Immunization Forms Reviewed Clearance Date:

Cori Form Sent? Clearance Date:

Orientation: HIPAA

Cambridge Health Alliance Volunteer Services * 230 Highland Ave. Somerville, MA 02143
 CORI REQUEST FORM
Cambridge Public Health Commission has been certified by the Criminal History Systems Board for access to conviction and pending
criminal case data. As an Applicant/Employee for ___________________________, I understand that a criminal record check will be
conducted for conviction and pending criminal case information only and it will not necessarily disqualify me. The information below is
correct to the best of my knowledge.

_________________________________
Applicant/Employee Signature Name of Manager to be Notified of CORI Results

========================================================================================================

________ ____
LAST NAME (Print Clearly) FIRST NAME MIDDLE NAME

_____________________
MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH

__________________________ _______ - _______ - _______ _______________________________

DATE OF BIRTH SOCIAL SECURITY NUMBER * ID THEFT INDEX PIN
(Requested, not required) (If applicable)

________________________________
MOTHER’S MAIDEN NAME

CURRENT AND FORMER ADDRESSES:

CURRENT ADDRESS: ___________________________________________________________________________________

DATES FROM: _______________ TO: ____________________

PREVIOUS ADDRESS (1): _________________________________________________________________________________

DATES FROM: _______________ TO: ____________________

PREVIOUS ADDRESS (2): _________________________________________________________________________________

DATES FROM: _______________ TO: ____________________

========================================================================================================

SEX: _______________ HEIGHT: ft. in. WEIGHT: EYE COLOR: _____________

STATE DRIVER’S LICENSE NUMBER: _______ STATE: ________________

THE INFORMATION WAS VERIFIED WITH THE FOLLOWING FORM OF GOVERNMENT ISSUED PHOTOGRAPHIC

IDENTIFICATION: COPY OF PHOTO ID MUST BE ATTACHED TO THIS

FORM

REQUESTED BY: _______________________________________________

SIGNATURE OF CORI AUTHORIZED EMPLOYEE

* The CHSB Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft PIN Number by
the CHSB. Certified agencies are required to provide all applicants the opportunity to include this information to ensure the accuracy of the
CORI request process. November 2009
One Volunteer Opportunity (many more online at:
http://www.challiance.org/howyoucangive/volunteer/opportunities.shtml)

Hand Hygiene Pilot Program

Title: Promoting a culture of safety; empowering staff to improve hand hygiene compliance

Schedule/hours: 3 hours weekly

Assignment description: After education, volunteers will distribute "life-saver" tickets to staff who
practice hand hygiene before and after contact with patients or their environment
Duration: academic year
Address/location where volunteer should report: a Cambridge Health Alliance inpatient facility in
Cambridge, Somerville or Everett

Aim: To prevent the spread of healthcare-associated infections by promoting a comprehensive Hand

Hygiene Program throughout CHA. To foster a culture of good hand hygiene practice, in which all
members of the health care team help each other by giving and accepting gentle reminders to comply with
hand hygiene before and after contact with a patient or their environment.

First phase: Distribute positive reinforcement (i.e., life-saver tickets and an individually wrapped life
saver) to compliant staff.
Second phase: Distribute positive reinforcement (i.e., life-saver tickets and an individually wrapped life
saver) or a "reminder" ticket along with education about the need for hand hygiene after a specific task to
non-compliant staff.
Staff and managers will be alerted to this initiative and volunteers will wear a "Life-Saver" shirt to
identify them as a Hand Hygiene Facilitator.

Hand-Hygiene Facilitators will receive comprehensive education on the indications for hand hygiene
and appropriate techniques for hand disinfection. They will be provided tools and learn skills to promote
optimal hand hygiene among healthcare workers, patients and families. Facilitators will work directly in
the hospital setting.

Who Should Become Involved? This is an ideal community service project for students with an interest
in healthcare, patient safety, human behavior, or epidemiology. Participants will be actively engaged with
members of the Infection Prevention and Control Department, Hand Hygiene Improvement Teams, Hand
Hygiene Champions and unit managers. Facilitators will have the opportunity to interact with physicians,
nurses, nursing assistants, technicians and students. We seek polite, respectful, friendly and outgoing
individuals who have a strong desire to improve patient safety.