ICUBP Application Form 1 (PDF Create)

Thank you for considering applying to the ICU Bridge Program!

The application process will take ~20 minutes, provided that you have reviewed our website (www.icubridgeprogram.org/apply) and accompanying files have been prepared.

Form 3, which includes our optional equity and diversity survey, should take an additional 12 minutes.

If you use the same browser, all responses (except for signatures and attachments) will remain and be saved for 24 hours.

As a potential ICU Bridge Program volunteer, I understand that my volunteer position is never guaranteed at my hospital of choice and is subject to delays or refusal at any time in the application process.

I consent to:

1. Reading and understanding all sections of the ICU Bridge Program website (http://www.icubridgeprogram.org).
2. Responding to ICU Bridge Program emails and instructions in a timely and appropriate fashion.
3. A minimum of one semester of volunteering and shadowing.
   1. This includes committing to my weekly 4 hour shift, as a repeated presence and familiarity with the role is essential to gain the most from volunteering and shadowing.
4. Notifying the co-directors and the executive team of the program of:
   1. Ways in which the program can be improved.
   2. Any issues that I’ve encountered while volunteering or shadowing.
5. Act in a professional and respectful manner and represent the ICU Bridge Program to the best of my abilities and give my maximal effort to improving both the program and the ICU that I am stationed at.

The law stipulates as follows:

The medical records of the recipients in an establishment shall be confidential. No person shall give or take verbal or written communication of them or otherwise have access to them, except with the express or implied consent of the recipients receiving services from the establishment.

Confidentiality extends to everything hospital personnel learn in the exercise of their duties–whether it is written, verbal, or other form. It includes important and “unimportant” information.

• Consult and/or read charts, x-rays, or lab reports being delivered to a physician’s office;
• Leave test results, charts, etc., placed in your custody laying about on a desktop or in corridors.
• Mention who you have seen coming to the hospital for a treatment

Students must immediately notify the ICU Bridge Program co-directors and the executive team of any situation that may jeopardize the confidentiality of our patients, staff, and organization.

Failure to maintain confidentiality is a serious breach of our Code of Ethics and may result in termination of your shadowing and volunteering opportunities with the ICU Bridge Program.

I hereby authorize the ICU Bridge Program, and those acting pursuant to its authority to: 

1. Record my likeness and voice on a video, audio, photographic, digital, electronic, or any other medium.
2. Use my name in connection with these recordings.
3. Use, reproduce, exhibit, or distribute these recordings in any medium (e.g. print publications, video tapes, CD-ROM, Internet, including social media and the ICU Bridge Program Facebook page) for any purpose that the ICU Bridge Program, and those acting pursuant to its authority, deem appropriate, including promotional, or advertising efforts.

I release the ICU Bridge Program and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of the ICU Bridge Program. Where photos or other recordings are used on social media outlets, their use also may be subject to the terms and conditions of those websites.

 Confidentiality Agreement

As volunteers in the health care system, we all have a moral responsibility to protect the confidentiality. Each patient entering the hospital should feel at ease knowing that his dignity and privacy will be respected. Individuals and institutions can be held legally responsible for any breaches of a patient’s confidentiality and can be sued.

 

The law stipulates as follows:

 

The medical records of the recipients in an establishment shall be confidential. No person shall give or take verbal or written communication of them or otherwise have access to them, except with the express or implied consent of the recipients receiving services from the establishment.

 Confidentiality extends to everything hospital personnel learn in the exercise of their duties whether it is written, verbal, or other form. It includes important and "unimportant" information.

• Consult and/or read charts, x-rays, or lab reports being delivered to a physician's office.
• Leave test results, charts, etc., placed in your custody laying about on a desktop or in corridors.
• Mention who you have seen coming to the hospital for a treatment.

Volunteers are responsible for maintaining the confidentiality of all proprietary or privileged information to which they are exposed while serving as a volunteer whether this information involves a single member of staff, volunteer, patient, or other person or involves the overall business of the hospital.

Volunteers must immediately notify their supervisor and the Director of Volunteer Services of any situation that may jeopardize the confidentiality of our patients, staff, and organization.

Failure to maintain confidentiality is a serious breach of our Code of Ethics and may result in termination of your relationship as a volunteer at the McGill University Health Centre.

I understand that if I violate the confidentiality of information or if I fail to take reasonable measures to avoid the disclosure of confidential information, I shall be liable to action up to and including termination of my volunteer assignment, depending on the seriousness of the violation.

I certify that I have read this document and that I have understood the meaning and consequences thereof.

As a volunteer, you may be exposed to patients with infectious diseases.

Alternatively, if you contract an infectious disease and come to volunteer, you pose a risk to the hospital population, including vulnerable patients to it.

Consequently, it is mandatory to provide evidence of immunity for the following vaccine-preventable diseases:

1. COVID-19 (No longer mandatory, but we strongly encourage you to provide if you have them)

1. Pertussis
2. MMR: Measles, Mumps, Rubella
3. Varicella (Chicken Pox)

Proof of immunization and/or required required doses for these diseases will be requested in Form 2.

1 dose is required after age 14 :

2 doses of MMR required:

Proof of vaccination required. If you have:

• Been vaccinated before age 13: 1 dose
• Been vaccinated after age 13: (VARIVAX) 2 doses one month apart are required
• Not been vaccinated: Positive serology (blood test) for varicella

 

French

We understand that a large portion of our volunteers are international students who are not comfortable speaking French. Regardless, due to the bilingual hospital environment, applicants should have a functional grasp of both English and French to interact with our patients and families (volunteers should be able to understand and respond in both languages).

The ability to communicate in French is crucial to reducing the stress of concerned friends & family members and volunteers should be able to communicate with visitors independently. Due to the many factors that are considered when creating the schedule, it is not always possible to pair less fluent French speakers with more fluent French speakers.

Other Languages

The ICU Bridge Program is also interested in understanding what other languages our volunteers are fluent in. By providing this information to the hospital staff, the program can possibly further support patients in different situations. Please answer the following questions in reagard to your fluency in languages other than english and french.

Include in the textbox below:

1. A single short sentence describing any hobbies or extracurriculars you partake in.

2. A single short sentence describing your ideal shadowing experience.

The descriptions of all the volunteers will be put together and be acccesible to our ICU staff and ICUBP executive teams so that they can get to know the ICU volunteers better.

Please specify anything you want to add or clarify with regards:

- To your application

- To ways you believe this application process can be improved

By selecting the submit button below I certify that I have read and understood the contents of the ICUBP website and forms. All the information provided in this form is accurate and complete, according to the instructions provided.

If you've submitted the form successfully, you will:

1. Be re-directed to Form 2 of the ICUBP application process.
   1. Please ensure you allow pop-ups from this page to be redirected properly.
2. Receive a summary email with your Form 1 responses and a dowloadable PDF to be used for Form 2.

If you are unable to submit the form or do not receive an email within 5 minutes, please try submitting the form using another browser. If you are still having issues after using an alternative browser, please email us at: info@icubridgeprogram.org.