VOLUNTEER SERVICES DEPARTMENT REQUEST FORM
Date:___________________________
Department: _________________________________ Location:__________________________________
Person(s) Requesting Volunteer(s):
Contact Person: _______________________________Secondary Contact:__________________________
Phone Number: _______________________________ Phone Number: _____________________________
E-mail Address: _______________________________ E-mail Address: _____________________________
DUTIES
What are the duties you will assign to the volunteer(s)?
What are the opportunities and/or experiences the volunteer will gain from this assignment?
**If your assignment is CLERICAL ONLY, please note that Labor Relations guidelines limit volunteer support to no more
than 4 hours a day, twice a week. A maximum of 2 administrative support volunteers may be assigned to a department and should not be utilized in place of hiring staff.**
SUPERVISION
Who will be the person responsible for supervising the volunteer(s)?
Name:_______________________E-mail:________________________ Phone:________________
SCHEDULE
What days of the week and time of day are your preference for volunteer support?
Days:______________________________________ Hours:______________________________________
Minimum Commitment:
Summer Student (8 weeks)
Year-Round Program (6 months)
Other (Specify commitment ___________________)
AGE REQUIREMENT
Number of volunteers needed in each category:
Summer Student Program
High School I (14-15 years old) ______________
High School II (16-17 years old) _____________
(# of volunteers desired)
(# of volunteers desired)
Year-Round Program
16-17 years old ______________________
18+ _______________________
(# of volunteers desired)
(# of volunteers desired)
APPROVAL
Request Form must be approved by Department Manager. Please provide name and date of approval.
Manager :_______________________________ Date:_____________________________
(if e-mailing, use initials)
ACKNOWLEDGMENT OF RESPONSIBILITY
I have reviewed the supervisory roles and responsibilities and will implement the program according to the
Volunteer Services Policies and Procedures.
Signature (if e-mailing, use initials)
Date
Print Name Department
All Volunteers must complete the following requirements prior to their start date:
* Complete an application
* Attend a mandatory 1 hour Information Session & 3-hour Volunteer Services Department Orientation or
pre-arranged volunteer session
* Schedule an interview with the Manager or Coordinators of Volunteer Services.
* Complete a background check
* Complete Privacy and Security Policies, Infection Control review and Hand Hygiene Review
* Provide vaccination records for two negative TB skin tests or 1 Negative QuanitiFeron Blood test result
and 1 negativeTB skin test (or negative chest x-ray results if TB test is positive), MMR (Measles, Mumps, Rubella)
and Chicken Pox (Varicella). In addition, all volunteers must receive an annual Seasonal Flu Vaccine and a
one-time Tdap vaccine prior to first day of service.
* Meet with supervisor and return signed referral form with start date and schedule
* Obtain ID badge and volunteer uniform
* Record volunteer hours with the Department of Volunteer Services
Please return completed request form to:
Vicki Kleemann, Manager, Volunteer Services: [email protected]
Volunteer Services Department - Parnassus
505 Parnassus Avenue, M-167, Box 0208, SF CA 94143
PHONE: 415-353-1196 FAX: 415-353-8943
www.ucsfhealth.org
Volunteer Services Department - Mission Bay
1975 4th Street, Room C-1948, Box 4014, SF CA 94143
PHONE: 415-476-1415 FAX: 415-476-4001
www.ucsfhealth.org