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APPLICATION

Thank you for your interest in Volunteer opportunities at Cleveland Clinic.

Please note that upon acceptance, you must submit proof of your COVID 19 vaccination.

Date of Application:

M-D-Y

Previous Volunteer Application and / or Service Experience at a Cleveland Clinic Location:

Preferred Name Prefix:

Applicant Legal First Name:

* must provide value

Applicant Legal Last Name:

* must provide value

Preferred Name:

Preferred Name Suffix:

Please share "Other" Preferred / Suffix

Date of Birth:

M-D-Y

Gender

How do you self describe your gender:

Race:

Describe other race:

Primary Phone:

* must provide value

Primary ______ number:

* must provide value

Secondary Phone Number

Preferred Phone Most Used:

My preferred ______ number Is:

I give consent for texts to come from the Cleveland Clinic Volunteer Program to my cellular device.

Yes

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Our primary mechanism of keeping volunteers informed is through email.

Please provide your email address (if you do not have email please enter the word none)

* must provide value

My Preferred Method of Contact:

Country of Permanent Residence:

* must provide value

Other Country:

Permanent Street Address Line One:

* must provide value

Permanent Address Line Two:

Permanent City of Residence:

* must provide value

Permanent State of Residence:

Permanent Territory of Residence:

Other Territory:

Permanent Residence Zip Code:

* must provide value

Emergency Contact First & Last Name:

* must provide value

Emergency Contact Phone Number:

* must provide value

Emergency Contact Relationship:

Highest grade or year of school completed:

* must provide value

Cleveland Clinic volunteering requires volunteers to be at least 15 years of age.

Primary Language Spoken In My Home:

* must provide value

Describe Other Language:

Second Language Spoken in my Home:

Describe Other Language:

Occupation

* must provide value

How might you describe your role with ______?

Please describe "Other" occupation category:

I am a current or former employee of Cleveland Clinic:

* must provide value

Yes

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Area of employment at Cleveland Clinic (Location, Unit / Department, Role):

I am related to a current Cleveland Clinic Caregiver, Board Member, or Trustee of Cleveland Clinic:

* must provide value

Yes

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Relative role, work/service location, name:

Did someone refer you to Volunteer Services?

* must provide value

Yes

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Please share the name of the person(s) or event that referred you to Cleveland Clinic Volunteer Services and the circumstances:

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I discovered Volunteer Services in this way:

Current Volunteer

Caregiver (Employee of Cleveland Clinic)

Cleveland Clinic Website

Social Media

Special Event / Recruitment

My Cleveland Clinic Provider (Primary care, Specialist)

School (High school, College, University)

Community

Other

Volunteer Service Interest:

* must provide value

Traditional Volunteer

Caring Canine Volunteer Program

Hospice Program Volunteer

Spiritual Care Volunteer Program

ADRC (Lutheran Hospital)

Concert Band Program

College Volunteer Program

Teen Volunteer Program

Healthcare Partner Volunteer (Adult Area - a Healthcare Partner acts as a patient or family advisor on a designated committee or project)

Healthcare Partner Volunteer (Pediatric Area - You must be a patient, parent or guardian of a patient with Cleveland Clinic Children's to participate in this advisory program)

I need more information before I choose

Other

I would consider learning about and then deciding whether I would like to participate in changing the delivery of healthcare and enhancing the Cleveland Clinic patient and caregiver experience if one of the opportunities became available as a one opportunity or short term project:

* must provide value

Joining a group that meets regularly

Working on a special project with defined goals

Offering input on construction and space planning such as exam rooms and waiting areas

Joining a committee focused on patient safety, quality standards or ethics

Speaking publicly about your Cleveland Clinic patient experience to large groups

Speaking publicly about your Cleveland Clinic patient experience to small groups

Writing about your Cleveland Clinic patient experience

Participating on research projects (such as improve patient experience, etc.)

Responding to surveys or electronic feedback

Videoconferencing in to meetings

Peer to Peer Networking & Support

Joining a committee focusing on patient & family advisory (Healthcare Partner) council program growth / strategy

I am not interested

THANK YOU for your interest in Healthcare Partner service for Children's Hospital.

This program seeks to engage the voices of those families who have been PATIENTS (or parents of patients) of Children's Hospital.

I am the parent or legal guardian of ______ ______ and I grant permission for him / her to apply to a Cleveland Clinic Volunteer Services program.

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Please print the name of the parent or legal guardian that granted permission for this application by signing above.

Describe "Other" Volunteer Opportunity of Interest:

Your Dog's Name:

______'s approximate Date of Birth:

D-M-Y

Canine needs to be greater than one year of age in order to volunteer at Cleveland Clinic.

How long have you had ______:

What breed of dog is ______:

Any Additional Information about ______ that may be important:

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The Healthcare Partner program is interested in your input and input from other patients, families or support persons, how would you like to provide input? For example: (read list below):

Joining a group that meets regularly (once per month or once per quarter)

Working on a special project with defined goals

Offering input on construction and space planning such as exam rooms and waiting areas

Joining a committee focused on patient safety or quality standards

Joining a committee focused on ethics

Speaking publicly about your experience (Caregiver meetings, Town halls)

Participating on research projects (to improve patient experience, not medical / clinical)

Responding to surveys or electronic feedback

Videoconferencing in to meetings

Peer to Peer Networking & Support

Joining a committee focusing on Healthcare Partner program growth / strategy

Volunteering in the Our Voice: Healthcare Partner program office

If sharing your point of view is part of your role, the focus will be on:

A patient (yourself)

A patient for whom you are/were a primary, designated support person

A patient for whom you provide support as family member or loved one

What excites you about being a Cleveland Clinic Volunteer?

* must provide value

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What is one thing you would like to see Cleveland Clinic do differently?

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Commitment Overview and Confidentiality Agreement

Cleveland Clinic Volunteers are patients, family members and/or support persons who work together with Cleveland Clinic Caregivers to transform healthcare and support our vision of Patients First and providing relationship-centered care.

Vision: Patients, support persons and caregivers as partners for better health

Mission: Improving Healthcare through collaboration

Volunteers serve in many different ways to improve healthcare through collaborative efforts with leadership, caregivers, healthcare partners and the community. The Cleveland Clinic appreciates the critical role you will play in transforming healthcare.

Participation may occur throughout the Cleveland Clinic including main campus, regional hospitals, outpatient family health centers and primary care practices.

As a Volunteer, you will be invited to share your perspective on the Cleveland Clinic, its culture, approaches to and delivery of care and the patient experience. Often this will occur in a group setting with other participants present; and therefore, some confidentiality may be lost by revealing information in a group setting. We ask that you respect one another's' confidentiality and not discuss names or other identifying information of patients, families, and support persons connected with the program or the Cleveland Clinic. Similarly, the Cleveland Clinic will not share any individually identifiable information obtained as a result of participating in the Our Voice: Healthcare Partner program. More specifically:
• Confidential information may be discussed between Volunteers and
Cleveland Clinic Caregivers. Such confidential communications must be
kept confidential and within participants of this program.
• You may not communicate confidential information outside of the
Volunteer scope of service or direct others to undertake aspects of the
work.
• You must respect the private and sensitive nature of this program.
• All information shared during or related to this program shall be used
only within the context of this program.

Participants selected to be Cleveland Clinic Volunteers are asked to commit to one year of service. An option to rejoin for one additional year may be discussed at the conclusion of the first year of service. Cleveland Clinic may remove a participant from the program at its discretion.

There will be no compensation for participation.

Participants selected will complete an on-line on boarding process, attend an orientation session and receive information regarding the specific schedule required for their assignment prior to their start.

By signing below and participating in the Cleveland Clinic Volunteer Program, you understand that you are choosing to abide by the guidelines described above. While the Cleveland Clinic respects and abides by its regulatory obligations regarding privacy and ensures all reasonable measures are taken to protect information, it may not be able to completely safeguard the privacy and confidentiality of what you choose to discuss or responses offered. Therefore, you agree that the Cleveland Clinic shall not be liable for any financial or other damages resulting from the shared nature of this program and/or other participants in the program. In accordance to the Cleveland Clinic's commitment to maintaining the privacy of its patients, you also agree to protect the privacy of other CC Volunteers by not identifying other participants or discussing their personal information and/or medical condition outside of the Volunteer Program.

By signing below, I acknowledge that I have read and agree to abide by the requirements stated above.

(Click Add Signature and use your mouse to sign your name in the box below)

* must provide value

Add signature

6a - 8a

8a - Noon

Noon - 4p

4p - 8p

8p-midnight

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

I would consider attending meetings virtually (from a distance by computer) using the following ways to connect:

Zoom Meeting

Microsoft Teams

Google Hang Out

Skype

GoToMeeting

Cisco WebEx Meeting Center

FaceTime

I would not attend a meeting virtually.

I am most interested in volunteering at:

* must provide value

Hospital

Family Health Center / Medical Office Building / Outpatient

Hospice (Available in Ohio Only)

Other

Describe "Other" area of volunteering:

I am most interested in volunteering at this hospital:

* must provide value

I am most interested in volunteering at this Family Health Center / Medical Office / Outpatient Setting:

* must provide value

Alert: Akron General Volunteer Services Department completes Background checks, inclusive of fingerprinting, for all volunteers.

I am most interested in volunteering with:

* must provide value

Adults

Infants (Less than 2 years old)

Children (ages 2 - 12)

Teens (13-18)

Hospice patients (available in Ohio only)

Roles with no patient contact

Cleveland Clinic Caregivers (Caregivers refers to those who are employed to work at Cleveland Clinic)

Opportunities to volunteer with Infants and Children patients are not available at the following locations at this time:

Cleveland Clinic Family Health Centers & Medical Office Buildings
Hospice
Ashtabula County Medical Center
Avita Health System Bucyrus Hospital
Avita Health System Galion Hospital
Avon Hospital
Cleveland Clinic Abu Dhabi
Cleveland Clinic London
Cleveland Clinic Weston Florida
Euclid Hospital
Hospice Care
Indian River
Justin T Rogers Care Center / Hospice Care
Lodi Hospital
Lutheran Hospital
Lou Ruvo Center for Brain Health
Martin North Hospital
Martin South Hospital
Martin Tradition Hospital
Marymount Hospital
Medina Hospital
South Pointe Hospital
Union Hospital
Weston Hospital

I have previous and / or current volunteer experience.

* must provide value

Yes

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I have had previous Hospice experience.

Yes

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Please share more about your Hospice experience:

Dates of Service with Hospice

Role with Hospice

Relationship with Hospice

Location(s) Served

Any Additional Information

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Please share your previous volunteer experience information:

Location of Service

Dates Served

Approximate Hours contributed

Reason for discontinuing service (if applicable)

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Please download, read, and save a copy of Cleveland Clinic Volunteer Handbook

Attachment:

Volunteer Handbook 20-CCC-1885659.pdf

I did download the Volunteer Handbook using the link above.

Yes

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I acknowledge receipt of the Cleveland Clinic Volunteer Handbook.

I acknowledge that I have read and understand the content of the Cleveland Clinic Volunteer Handbook and accept full responsibility for familiarizing myself with the policies contained within,

I understand that the information contained in the Volunteer Handbook may be updated periodically and that I can obtain updated policies and information by contacting my Cleveland Clinic Volunteer Coordinator or Volunteer Services at 216.445.6986.

I recognize that the Volunteer Handbook, as well as any written or oral communication made at the time of
commencement of volunteer work, or subsequently, is not intended in any way to create a contract between Cleveland Clinic and myself. I understand that volunteerism does not create an employment relationship and the volunteer relationship is entered into voluntarily and many be terminated by Cleveland Clinic or me at any time regardless of circumstance.

I understand that Volunteer Services at Cleveland Clinic may involve service that may create hazards to me, including but not limited to lifting and carrying heavy items. I understand that it is my responsibility not to engage in tasks that are beyond my physical limitations and abilities and will notify CC Volunteer Services Coordinator or Volunteer Services at 216.445.6986 if I believe this is ever the case.

I understand that, for safety purposes, Cleveland Clinic completes background checks on volunteers.

If I have any questions about the content, interpretation or application of the Volunteer Handbook to me, I agree to immediately bring any questions to the attention of a Volunteer Coordinator.

I understand that the information, observations, and knowledge gained through my participation as a Cleveland Clinic Volunteer must not be used for personal, professional, or business gain inside or outside of the Cleveland Clinic.

I attest to that I read, understood, and agree to abide by the content of the modules that are listed below. If I have any questions regarding understanding and execution of the content of these modules, I will contact Cleveland Clinic Volunteer Services Department at 216.445.6986 for further instruction. I understand that review of additional materials may be required in the future, and if that is the case, I will be notified.

i. Corporate Compliance: Prevention, Detection, and Reporting
ii. HIPAA Overview
iii. Information Security Awareness
iv. Stroke: Overview for Caregivers
v. Diversity and Inclusion
vi. SERS for all Caregivers
vii. Patient Safety

Please add signature below:

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Next Steps

A Volunteer Coordinator will be in touch with you within 5 - 10 business days of this application to assist with these next steps.

Acceptance into the Cleveland Clinic Volunteer Program, is not automatic. In addition to this application, placement will be determined by: Interview, Availability of Opportunities, and successful progression through TB testing & designated Cleveland Clinic Non-Employee onboarding software.

1) Applicant Interview

2) Applicant designated Cleveland Clinic Non-Employee Onboarding software program

completion, including background check conducted by Cleveland Clinic.

3) TB testing

4) Fingerprinting (additionally required if volunteering with / near children, & as needed if

volunteering with vulnerable populations)

5) Watch Cleveland Clinic Orientation

6) Site Specific Orientation

7) Obtain badge

8) Parking (as applicable)

I am a United States citizen:

* must provide value

Yes

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Please share your VISA type, for further consideration.

Individuals who are not U.S. citizens, but who reside in the U.S., may volunteer

(1) if they are a lawful permanent residents; or

2) if they are non-immigrant aliens with F-1 or J-1 visa status, who are bona fide students residing in the U.S. solely to pursue a course of study at a recognized, approved institution of education.

Foreign students may volunteer with a Federal natural resource agency if they have successully received permission to engage in Optional Practical Training (OPT), Curricular Practical Training (CPT) or Academic Training (AT).

For more information and instructions, students should consult the international student advisor at their university. An offer of employement or verification of a volunteer placement must be submitted with the student's application for OPT, CPT or AT. F-1 student visa holders may be required to submit applications for off-campus training and work to the international student advisor and United States Citizen and Immigration Services (USCIS) several months in advance of the proposed start date of the program. J-1 student visa holders may participate in academic training with the approval of their academic advisor and the J-1 responsible officer at their sponsor organization or institution.

Source:https://www.volunteer.gov/faq.cfm

Thank you for your interest in Cleveland Clinic Volunteer Program.

Please share anything more that you would like us to know, below:

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I acknowledge the following:

I acknowledge the answers given here are true and complete. I realize that my potential volunteer service in no way commits Cleveland Clinic to future employment.

* must provide value

NOTES:

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