Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
S.H.O.W. Clinical/Preceptor Application
Thank you for your willingness to volunteer with S.H.OW. Please complete the following application and emailed to: Dr.Liz Harrell () AND Tammy Krause ()
A full list of volunteer requirements can be found attached to this document. Do not submit them at this time. After reviewing your application we will send you and email with any additional paperwork and a list of requirements for submission.
We look forward to working with you.
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Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
First Name: / Last Name:Email address: / Preferred name:
Employer:
Employment address:
Street / City / State / Zip
Home address :
Street / City / State / Zip
Work Phone: / Cell Phone:
Emergency contact (name):
Relationship: / Emergency contact phone number:
University Affiliation (if applicable) / Professional Specialty:
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Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
Clinical & Program Interests: Please check all that apply
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Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
Preceptor for Teaching Team (supervise clinical students as part of an interprofessional team)
Provider Team (no teaching or supervision responsibilities)
Supervise student facilitated Health Promotion/Prevention programs and activities
Supervise student navigators and waiting room student meet & greeters
Mentor to a S.H.O.W. student subcommittee (i.e. Clinical Operations, Research & Quality Assurance, Volunteer Management & Human Resources, Technology, Fund Development and Sustainability, Communication & Public Relations, Programming & Special Events)
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Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
Other Skills: Please check or list all that apply
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Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
Clinic Management
Business Management/Finance
Research
Quality Improvement
Program Evaluation
Fundraising
Health Program Design or Development
Technology skills (website, programming, database management, graphic design)
Photography
Videography
Human Resource & Volunteer Management
Policy & Procedure development
Training – List Area(s) of Certification ______
Marketing & Public Relations
Arts
Music
Other (Please list)______
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Student Health Outreach for Wellness (S.H.O.W.)
550 N. 3rd Street, NHI-2 #204 BB
Web: showaz.org
Signature / DatePrinted name
Volunteer Requirements
Volunteer Requirements are based on your role within S.H.O.W. Please note that Student Clinical Volunteers include any student who will be working with patients/clients. Student volunteers must be a student of ASU, NAU or U of A.
Once you have submitted your application and it has been reviewed you will be asked to submit documentation of the requirements list below and may be asked to complete additional forms which will be sent to you at that time. Please begin to gather this information in preparation.
Committee / Faculty Mentor / Research Committee / Student Clinical Volunteer / Front Desk / Clinic Preceptor/ProviderRequired
Volunteer Application / x / x / x / x / x
CITI Training
Update every 4 years / x / x / Faculty: Required
Community: Not Required
TB Skin Test
Annually / x / x / x
Vaccination: MMR Series
(or proof of immunity) / x / x / x
Vaccination: Hepatitis B Series
(or proof of immunity)
Waiver available upon request / x / x
BLS/CPR
Every 2 years / x / x
HIPAA Training
Annually / x / x / x / x
Blood Borne Pathogen
Annually / x / x / x
Board Certification
(if applicable) / x
DEA License (if applicable) / x
State Licensure (if applicable) / x
Credentialing paperwork / MD/NP/PA providers only
Recommended / Preferred
Vaccination: Influenza annually / x / x / x / x
Vaccine: Hepatitis A Series / x / x / x
Vaccine; Tdap or Td / X / x / x / x
ACLS
Update every 2 years / x
Dispensing Privileges (if applicable) / x
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