PT Volunteer Request PT Volunteer Request Requestor InformationRequestor Name(Required) First Last Requestor Email(Required) Will you be the faculty supervisor for this volunteer position?(Required) Yes No Your Phone Number(Required)Who will be the faculty sponsor for this volunteer position?(Required) First Last Supervisor's Phone Number(Required)Supervisor's Email(Required) Volunteer Applicant InformationName First Last Email This individual is a:(Required)Choose Onenon-UF student volunteering to gain experienceUF student volunteering to gain experienceUF student volunteering for course creditUF student interning for academic creditnon-employee clinicianUF DPT student volunteering outside of course requirementsIs the volunteer applicant related to a current PHHP employee or faculty member?(Required) Yes No Unknown Name of relative:(Required) The UF Regulation 1.009, Employement of Relatives, specifically prohibit relatives from volunteering in any position where a direct or indirect supervisory relationship between relatives would exist, or where a perceived or actual conflict of interest would be be created. Your PT HR generalist will provide you with further information regarding this request.Is the volunteer applicant a minor?(Required)Minors, aged 14-17, are not prohibited from volunteering, but there are additional limitations and requirements. We will reach out with this information. Yes, age 14-15 Yes, age 16-17 No PHHP policy prohibits minors related to current PHHP employees or faculty members from volunteering. Please contact our HR representatives with any questions. (JOSH _ SHOULD THIS HIDE THE REST OF THE FORM?)Volunteer PositionVolunteers are non-employees who xx, yy, zz. OR Tell us about the volunteer position you are wanting to fill. The following are not considered volunteers (quote from UF policy)This indivdiual will be volunteering:(Required) In a research lab At the equal access clinic At a one-time community outreach event (single day or consecutive days) At an ongoing community outreach activity Other This DPT student will be volunteering:(Required) At a one-time extracurricular student activity (single day or consecutive days) At an ongoing extracurricular student activity Other If other - description of volunteer activity:(Required) Anticipated Start Date(Required)Start dates are dependent on when the applicant completes their pre-volunteer requirements (paperwork, training, screenings, etc.). Please list the earliest date you would like them start, but be aware that they cannot start volunteering until we have sent you a confirmation. MM slash DD slash YYYY Anticipated End DatesBy default, volunteers are approved for a period of 1 year. Please list a date if you intend for their volunteer activities to end earlier. MM slash DD slash YYYY Date(s) of one-time extracurricular student activity:(Required) Date(s) of one-time Community Health Event:(Required) Anticipated Hours per Week(Required) Duties & Responsibilities of this volunteer(Required)Volunteers must be provided with a written list of duties and responsibilities. The information you provide here will be included in their volunteer approval letter.Description of the extracurricular student activity:Include a description of any patient/clinical aspects of the activity.Occupational Medicine(Required)Please check which, if any, of the below duties apply to this volunteer position? Animal Contact Asbestos Work Climbing Commercial Driver License Contact with Human Blood or (OPIM) Frequent Reaching Above Shoulder Heavy Lifting BioPath (risk group 3 agents in BSL3 lab) Kneeling Law Enforcement Noise (Work in Area of Excessive Noise) Operation of Special Purpose Vehicle Patient Contact (including Research Participants) Pesticide Use Repeated Bending Repetitive Pulling and Pushing Respirator Use Scientific Research Diving None of the above duties apply If OccMed review is required, what account should be used for payment authorization?(Required)Note that sponsored projects typically cannot be used to cover costs associated with volunteers. What building(s) and room number(s) will the volunteer be working in?(Required) Location(s) where Patient/Research Participant Contact will occur(Required)This is required for to add the individual to our self-insurance policy. HPNP (Add address) CLC (Add address) Dental Ground (Add address) CTRB (Add address) Dauer Hall (Add address) MBI (Add address) UF Health (Add address) Community Locations Other Other location where Patient/Research Participant Contact will occur:(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country This volunteer will need: Computer Login Access/Network Access P Drive Access Building Access None List the shared folder(s) this volunteer will need access to:(Required)P: Drive access cannot be requested until the applicant has completed the required training. We will communicate this to the applicant, but please aware of this delay. What building(s) will this volunteer need access to:(Required)Note that building access may be granted, but the individual can only volunteer when the building is staffed by a paid employee.