Welcome to the Sparrow Hospital Volunteer Services Department

Adult Community Volunteer Application

Volunteer Contact Information
First name
Middle name
Family/last name
Address/Apartment #
City
State
Zip/postal
Primary Number
E-mail
Secondary Number
Emergency Information (Person to be notified in the event of an Emergency)
Contact name
Primary Number
Secondary Number
Educational Information
High School
Date Graduated
Graduate?
Graduate?
Date Graduated
College/University
If yes, where:
Are you currently enrolled in school?
Work Experience
Are you currently seeking employment?
In the last 12 months, have you applied for employment at Sparrow?
Employer 1:
Name of Organization
Job Title
Date Worked From
Date Worked To
Employer 2:
Job Title
Name of Organization
Date Worked From
Date Worked To
Employer 3:
Name of Organization
Job Title
Date Worked From
Date Worked To
Volunteer Experience
Volunteer Organization 1:
Date Volunteered From
Date Volunteered To
Volunteer Organization 2:
Date Volunteered From
Date Volunteered To
What/who has motivated you to seek volunteer opportunities at Sparrow?
What do you want to achieve from your volunteer experience?
What skills do you have that you would like to share with Sparrow?
How would you like to be recognized for your service?
Describe your Patient/Family experience at Sparrow.
Which Sparrow department(s) and/or locations(s) did you or your family member receive services?
Please share your ideas or suggestions for improvement to add if you have been a patient at Sparrow.
Are you able to commit to at least one year of services?
Choice of Volunteer Position
First Choice
Second Choice
Third Choice
If you were preapproved for a specialized placement, who is your contact person?
Criminal Background Check
Have you ever been convicted of a misdemeanor or felony?
If yes, please explain
I hereby willingly consent to the completion of a background investigation and authorize Sparrow and/or its agents to request from any individual, company, firm, corporation, or public agency, including bona fide law enforcement agencies, any records or information pertaining to me. I further authorize any individual, company, firm, corporation, or public agency, including bona fide law enforcement agencies, to divulge any and all information, verbal or written, pertaining to me, including information or data received from other sources to Sparrow and/or its agents.

It is my understanding that any information obtained in the course of the background investigation will be held strictly confidential by Sparrow and its agents. Information gathered will be used only in connection with the volunteer placement process. I hereby authorize Sparrow and/or its designated agents and representatives to conduct a comprehensive review of my background, which may include information concerning my criminal, motor vehicle, and other history.

I understand this authorization automatically expires 90 days from the date executed below and that I have the right to revoke this authorization at any time, provided I do so in writing to Sparrow.
Full Name (First, Middle, Last)
Have you had a name change within the last seven years?
Please list any other name(s) used in the last seven years
Date of Birth
My typed name shall have the same force and effect as my written signature
Gender
Date
Nicotine-free Volunteer Policy Statement
To further our mission in providing quality, compassionate care to everyone, every time, effective April 1, 2012, Sparrow Health System will no longer offer volunteer placements to potential volunteers who use tobacco or nicotine products in any form. Sparrow promotes a healthy and safe environment for all Associates, Physicians, Volunteers, Patients and Visitors.

A nicotine user is any individual who uses nicotine products including, but not limited to, cigarettes, cigars, pipes and chewing tobacco. This policy also applies to e-cigarettes, which are regulated by the Food and Drug Administration as a nicotine product. Nicotine patches and gum are also included.
Do you use nicotine products?

Acknowledgement of Sparrow Health System CONFIDENTIALITY AND SECURITY OBLIGATIONS AND/OR CONDITIONS



As an Associate, physician, healthcare provider, contractor, or temporary employee or volunteer of a Sparrow Health System entity, you may have access to confidential information including patient, financial or business information obtained through your association with Sparrow Health System. The purpose of this Acknowledgement is to help you understand your personal obligation regarding confidential information.

Confidential information includes any information about a person's past, present, or future physical or mental health; the health care services provided to the individual or payment information related to such services, that identifies the individual or provides enough information that there is a reasonable basis to believe the information could be used to identify the individual.

Confidential information is valuable and sensitive and is protected by law and by strict Sparrow Health System policies. State law and the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), require protection of confidential health information. Inappropriate disclosure of confidential health information regarding patients may result in the imposition of fines on Sparrow Health System of up to $250,000 and ten years imprisonment per incident.
Accordingly, by signing this Acknowledgement and, having as a condition of and in consideration of my access to confidential information whether in oral, paper, electronic, or any other form, I acknowledge the following obligations and conditions of employment:

1. I am only allowed to access confidential information for which I have a legitimate need to know as part of my job responsibilities at Sparrow Health System and am only allowed to access information systems for which I am an authorized user. I am prohibited from removing any confidential information from Sparrow premises in any media including paper, magnetic disk, compact disk, video, recording, etc. without the express written permission of an authorized officer of Sparrow Health System. In addition, if I have remote access to Sparrow Health System information systems, I will not download or transfer any confidential files or data to my home personal computer.

2. I am prohibited from using or connecting to the personal computer assigned to me by Sparrow Health System, any equipment, modem, other hardware, or software without the prior written approval of Sparrow Health System -Information Services.

3. I am prohibited from discussing confidential information in any location at Sparrow Health System where it is likely that the conversation can be overheard by people who do not have a legitimate need to know the confidential information in order to perform their job responsibilities at Sparrow. I am required to return all recorded confidential information to its authorized, secure location in Sparrow Health System when I am done with it. I am prohibited from in any way from divulging, copying, releasing, selling, loaning, reviewing, altering or destroying any confidential information unless expressly permitted by existing policy or as properly approved in writing by an authorized officer of Sparrow Health System within the scope of my association with Sparrow Health System.

4. I am prohibited from utilizing another person's password in order to gain access to any information system. I am prohibited from revealing my computer access code to anyone else unless a confirmed request for access to my password has been made by Information Services and I am able to confirm the legitimacy of the request and the requestors. I am required to change my password immediately after it is disclosed to anyone. I am personally responsible for all activities occurring under my password.

5. If I observe or have knowledge of unauthorized access or divulgence of confidential information I am obligated to report it immediately to my supervisor or to Sparrow Information Security.

6. I am prohibited from seeking personal benefit or permitting others to benefit personally by any confidential information that I may have access to.

7. I acknowledge and recognize that I am prohibited from operating any software on the personal computer assigned to me by Sparrow Health System, other than those programs provided to me by Information Services, without the prior written approval of my supervisor.

8. I acknowledge that all information, regardless of the media on which it is stored (paper, computer, videos, recorders, etc.), the system which processes it (computers, voice mail, telephone systems, faxes, etc.), or the methods by which it is moved (electronic mail, face to face conversation, facsimiles, etc.) is the property of Sparrow Health System and shall not be used inappropriately or for personal gain. I also acknowledge that all electronic communication shall be monitored and subject to internal and external audit.

9. I acknowledge that my failure to fulfill the obligation or conditions in this Acknowledgement may result in disciplinary action, which might include, but is not limited to, termination of employment or, loss of my privileges within Sparrow Health System or other legal action.

By my signature below, I acknowledge that Sparrow Health System has an active on-going program to review records and transactions for inappropriate access and I acknowledge that inappropriate access or disclosure of confidential information contrary to or inconsistent with the conditions described in this acknowledgement can result in penalties up to and including termination of my employment and/or legal action against me.

My typed name shall have the same force and effect as my written signature
Date