SIGNATURE OF APPLICANT DATE
GENERAL HEALTH STATUS
Do you have any conditions/restrictions that would impact your ability to perform your volunteer duties safely? YES / NO
If yes, please describe: ____________________________________________________________________________________
Do you have any illnesses or conditions that could be transmitted to other personnel or patients during the course of your
duties? YES /NO
yes, please describe: ___________________________________________________________________________________
FLU POLICY: Please note that Island Health’s Influenza Policy applies to volunteers. This means that volunteers must be
immunized for influenza during onsite clinics or through other sources of vaccine such as Public Health Units, pharmacies or family
physicians. If volunteers choose not to or are unable to, they may wear a mask during flu season – approx. December 1 to March 31
annually. Volunteers who have been immunized are asked to inform their Volunteer Administrator of the date of their shot.
Have you ever had active Tuberculosis? YES /NO
Have you been experiencing any of the following symptoms for longer than one month?
Excessive fatigue: YES /NO
Unexplained weight loss: YES /NO
Persistent cough: YES / NO
Coughing up blood: YES / NO
Excessive night sweats: YES /NO Persistent fever: YES /NO
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE:
You will need to make an appointment with your family physician to rule out a communicable condition (such as active tuberculosis).
If a TB scratch/skin test is required you will need to go to the South Island TB Clinic or the nearest Public Health Unit. Inform the unit
that you are planning to volunteer at a VIHA Site. The results of your TB screening will need to be documented below and returned
to your Manager/Coordinator of Volunteer Resources before you may begin volunteering.
Volunteers who will be volunteering in high risk areas –
ERs, ICUs, Microbiology Lab and Cytology/Histology Lab, Respiratory
Therapy, Renal Units and dialysis units, Transplant Units, Respiratory units, Bronchoscopy and residential settings are
recommended to have the scratch/skin test done prior to starting their volunteer assignment.
Please Note: Volunteers who travel to areas of high TB prevalence (e.g. Brazil, China, India, Philippines, Thailand, remote areas in
Canada) may also be asked to have TB testing done upon their return. Please discuss this with your Manager, Volunteer Resources.
WILL RESPECT CONFIDENTIAL INFORMATION AND THE RIGHTS AND DIGNITY OF ALL PATIENTS AND RESIDENTS.
WILL HONOUR MY COMMITMENT AS A VOLUNTEER AND PROVIDE ADEQUATE NOTICE OF MY ABSENCES.
WILL ABIDE BY THE POLICIES AND STANDARDS OF THE DEPARTMENT OF VOLUNTEER RESOURCES.
IF APPLICANT IS A YOUTH (UNDER THE AGE OF 19), PARENTAL CONSENT IS REQUIRED. PLEASE SIGN BELOW:
SIGNATURE OF PARENT OR GUARDIAN NAME (PLEASE PRINT)