Thank you for your interest in joining the volunteer team at Loyola Medicine. All volunteers will be placed in non-clinical roles; we are unable to place volunteers in clinical roles.

To ensure the safety of our patients, visitors, colleagues and volunteers, all volunteers must participate in a screening/ onboarding process including an updated health screening and background check. This process will take 4-6 weeks to complete. Due to this lengthy process, volunteers are asked to serve on an ongoing basis.

You will be contacted by the Volunteer Services Department to discuss the next steps. Please do not volunteer at our vaccination clinics until these steps have been completed.


Personal Information

How did you hear about this volunteer opportunity?

Please indicate how you heard about this volunteer opportunity at Loyola Medicine.



Volunteer Interest

In a brief paragraph please describe why you are interested in volunteering at Loyola Medicine.



Volunteer Availability - COVID Vaccine Clinics

COVID Vaccine Clinics operate Monday through Friday 8AM to 8PM and weekend hours vary by location. Please indicate which days and times you will be available to volunteer on a weekly basis.



Site Preference(s)

Please check the box to indicate your preferences for volunteering at:

- Gottlieb Memorial Hospital in Melrose Park

- Loyola University Medical Center in Maywood

- MacNeal Hospital in Berwyn



Seasonal Flu Shot Verification

To ensure the safety of our patients, colleagues and volunteers, all volunteers must have proof of a flu vaccine or complete a medical/religious exemption. Please indicate when you received your flu shot and where you received it from. If you have not received your flu shot, this will need to be completed prior to your volunteer shift.



COVID-19 Vaccine

Have you received the COVID-19 Vaccine? If yes, please list the dates of your first and second dose.



Skills and Interests

Summarize special skills, training or qualifications you have acquired from employment, education, extracurricular activities or hobbies.



Volunteer Experience

Please describe any current or past volunteer experiences.



Emergency Contact

Agreement

By checking 'I agree'

- I certify that the statements made in this enrollment form are true and correct.

- I understand that I will not be paid for my services to Loyola Medicine and that my volunteer status may be terminated at the discretion of Loyola Medicine.

- I agree to log my volunteer hours on a regular basis.

As a volunteer at Loyola Medicine, I agree to:

1. Comply with HIPAA and hold as absolutely confidential all information obtained directly or indirectly concerning patients, doctors or personnel and not seek to obtain confidential information from a patient. Federal Regulations (42CFR Part 2) prohibits me from making any disclosure of such information without the written consent of the person to whom the information pertains.

2. Donate my services to Loyola without contemplation of compensation or future employment and freely give my services for humanitarian, religious or charitable reasons.

3. Report for volunteer service fit for duty, which means able to perform volunteer duties in a safe, appropriate, effective manner & conduct myself in the MAGIS Service philosophy of care, concern, respect and cooperation with other volunteers, hospital employees and staff, patients, and visitors. Anyone who is using prescription or over the counter medication, which may cause behavioral problems (i.e., drowsiness or irritability) or otherwise compromise the performance of the individual or other volunteers or hospital employees or staff, must inform the volunteer supervisor before beginning their volunteer duties.

4. Never give medical assistance and/or advice to the patient and his/her family. I fully understand that this is the responsibility of the professional medical staff.

5. Be punctual, conscientious and endeavor to make my volunteer services professional in quality.

6. To make my best effort to fulfill my commitment to Loyola Medicine by completing all assignments that I accept and follow the position description provided by the department.

7. To uphold the philosophy, standards and policies of Loyola Medicine and the volunteer department.

8. Meet compliance and safety standards by attending annual in-services or returning mailings in a prompt manner.

9. I understand that the Volunteer Services Department will provide written verification of my volunteer service after meeting all the requirements below:

+ Successful completion of the service requirement:

- Adults - One 4-hour shift each week for 6 months (at least 100 hours)

- Junior Volunteers - Two 4-hour shifts each week during summer break (at least 60 hours)

- College students - A minimum total of at least 100 hours

10. Review, understand and comply with the Volunteer Orientation.


Non-Disclosure of Confidential Information Agreement


1. I understand and agree that while providing volunteer services for Loyola Medicine that I may receive or learn of information concerning a patient’s medical history, diagnosis, condition, treatment, or evaluation. I understand that this information is classified as Protected Health Information (“PHI”) under various federal and state laws requiring confidentiality and privacy protections of such information.


2. I further understand that in connection with my services, I may also have access to other information and/or documents that are not generally known or readily available to the general public, which may include, but not be limited to, financial and social data relating to patients, business records, physician office records, x-ray films, and incident reports ("Confidential Information").


3. If I am provided access to the Loyola Medicine computer network through a sign-on identification code and password, I will use this sign-on identification code and password solely to obtain access to information necessary to fulfill my volunteer services. I shall not disclose to anyone my sign on identification code or password. I understand that any lost or disclosed sign-on identification code or password should be reported to my Volunteer Program Coordinator for follow-up procedures to correct and reassign as necessary.


4. I acknowledge that I have a responsibility to maintain the confidentiality of PHI, Confidential Information, and sign-on identification code(s) and password(s), and not to disclose such information to any person in the course of providing volunteer services unless that person is properly authorized to receive any such information.


5. I understand that my failure to maintain strict confidentiality of such Protected Health Information, Confidential Information, or sign-on identification code(s) and password(s), if appropriate, may result in immediate relief of my volunteer duties, and possible civil sanctions and criminal penalties.