M Health Fairview COVID-19 Vaccination Community Volunteer Application

Legal First Name:

Legal Last Name:

Last 4 digits of Social Security #:

Birthdate:

My work experience is (check all that apply):

Place of Employment:

If you are a part of a group, please provide your group name:

I have an active Minnesota medical license to practice healthcare. (Please note, only DDS/DMD, RN, LPN, MA, MD, DO, PA, NP and PharmD active Minnesota medical licenses are approved for the vaccinator role.):

Please provide your Minnesota healthcare license number. (required if you have an active MN medical license):

Please indicate type of Minnesota healthcare license (required for verification purposes):

Please provide the expiration date of your Minnesota healthcare license. (required if you have an active MN medical license):

Primary phone number:

Phone type:

Email:

Please indicate how many hours are you interested in volunteering. A 40 hour commitment over the course of several months that COVID vaccine clinics are in operation is preferred. (A typical shift is 4-5 hours and you may sign up for multiple shifts each week as available.)

At what geographic location do you prefer to volunteer? (Check all that apply)

Have you ever been convicted of, pled guilty or no contest to, any misdemeanor or felony criminal offense other than a minor traffic violation?

If yes, please provide the nature of the offense, the date, and the country and state in which it occurred.

A conviction or plea is not an automatic bar to volunteering.

In the past 3 weeks I have not had, been exposed to, and currently do not have the following:

• Chicken Pox/Shingles/TB
• Measles/Rubella/Mumps/German Measles/Whooping Cough, or other childhood diseases
• Cold/Cough/Sore Throat/Strep Throat
• Fever
• Rash or abnormal itching of body/scalp, Skin Sores
• Pink Eye or other eye infections
• Herpes Simplex/Cold Sores
• Any Infectious Condition
• Flu, or Flu-like symptoms

Are your immunizations up to date including MMR and Varicella:

Have you ever had a positive (+) result to a TB skin test or TB blood test ?

Have you ever been diagnosed with active or latent TB disease?

Have you had close contact or a known exposure to someone with active TB disease?

Have you ever spent more than 30 days in a country with an elevated TB rate? (This includes all countries except those in Western Europe, Northern Europe, Canada, Australia, New Zealand and the U.S.)

If your immunizations are not up to date, or you answered yes, to any of the TB screening questions, are you willing to update your immunizations including a TB test?

I am 18 years of age or older. (required)

I hereby grant and authorize M Health Fairview the right to take, edit, alter, copy, exhibit, publish, distribute, and make use of any and all pictures and video taken of me to be used in and/or for any lawful promotional materials including, but not limited to newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits, and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration.

By volunteering at M Health Fairview, you have obligated yourself to carefully refrain from discussing any patient's condition or personal affairs. Do not pass information to patients and visitors unless you have been given permission to do so by the supervisor/manager. In addition, all information seen or heard regarding patients, directly or indirectly, in completely confidential and is not to be discussed even with your family.

Your role as a volunteer requires that you govern yourself by high ethical standards. This includes not asking for clinical information about a patient nor seeking free clinical advice for yourself or your family members from doctors/staff. Failure to recognize the importance of confidentiality is not only a breach of ethics but could also involve a volunteer in legal proceedings.

The information on this application is true and accurate. It is my intention to volunteer and meet or exceed all standards and expectations outlined for me.

Please note, once your application is submitted, you will receive a link to required volunteer learning. This requires an attestation of understanding once completed.