Voluntary Services

01296 316676

Dear Applicant

Thank you for expressing an interest in volunteering for Buckinghamshire Healthcare NHS Trust.Please be aware you must be at least 17years of age - there is no maximum age limit.

Please find enclosed an application pack which contains:

  • A volunteer application form
  • An occupational health assessment form
  • Equal opportunities monitoring form
  • Identification requirements

We would respectfully ask you to read all the forms carefully before completing them. Once we have received your completed forms, we will invite you to arrange a suitable time for an informal discussion at one of our hospitals in Amersham, High Wycombe, Stoke Mandeville or Thame Hospital.If you have a disability, please contact us if you require any reasonable adjustments to be made during the meeting. If at any point you are unable to attend please let us know as soon as possible.

Please bring with you the relevant identification documentsrequired. These must be originals and within the specific dates as stated in the enclosed list. We will make copies on the day and return them to you. Suitable documents are noted in the application pack but a passport, birth certificate, drivers licence (both photo and paper version) are ideal, accompanied with something that can identify your home address (council tax bill, utility bill, credit card statement etc.). We need at least 3 documents.

If you do not bring your documentswith you, then this could delay your application and we will need to ask you to return with them.

Volunteers are subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it is a requirement that all volunteerscomplete a satisfactory DBS check (Disclosure & Barring Service check)before they start volunteering.You will be given details of how to apply when you come in to visit us.

There may be a slight delay whilst we wait for the result of your checks, however once you are cleared and we are ready to offer you a volunteering role we will call you to discuss your placement further.

A volunteer uniform (tabard or polo shirt) and ID badge will be issued to you when you start and must be worn at all times when you are volunteering. You will be required to pay a one-off £5 deposit for your uniform and ID badge. This will be refunded if you stop volunteering, provided you return your ID badge and uniform to voluntary services.

If you have any difficulty with completing the forms or have any further questions please call our office and we will be more than happy to help

We look forward to hearing from you

Voluntary Services

Buckinghamshire Healthcare NHS Trust

Volunteer Application Form

Please complete in BLOCK CAPITALSDate of application…………………………..

Title………………First name……………………………Surname…………………………………………….

Address…………………………………………….……………………………………………………………....

………………………………………………………………Postcode…………………………………………...

Tel no ………………………………………...Mobile…………………………………………………………....

Your email address

Date of Birth………………………………… Gender (M/F)…………………………………………………..

Emergency contact details: (Name and address) ………………………………….………………………...

………………………………..……………………………………………………………………………..……...

Tel No………………………………. ………. Relationship……..…………………………..………………...

What is the volunteering role you are applying for?

………………………………………………………………………………………………………………………

Where is the volunteering role? (Please circle)

Stoke MandevilleAmershamWycombeCommunity

What days/times are you available (please specify hours)

Mon / Tues / Weds / Thurs / Fri / Sat / Sun
Morning
Afternoon
Evening

Name of staff member managing the volunteering role:

Name:……………………………………………………….Tel no……………………………………………..

Email:………………………………………………………………………………………………………………

Why do you want to volunteer?

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

Are you currently employed?

 YesWhat is your job?......

 No

Are you currently studying?

 YesWhat are you studying?......

 No

Do you have experience of the following (please give details if relevant)

Previous hospital employment?…………………………………..……………………………………

Customer services?………………………………………….………………………………………….

Working with people?……………………………………………….…………………......

Working with computers?………………………………………………….……………………………

Are you able to commit to 6 months or more of regular volunteering on a weekly basis?

 Yes

 NoWhat can you offer?......

Please circle your mode of travel: Car Public Transport Walk

Distance in miles from your home (if known) …………………….

REFERENCES

Please give the details of two referees. These should not be family members, but must be someone who has known you for at least 3 years. To help speed up the application process please inform your referees that we will be contacting them and check the email address you give is correct as errors will delay the process.

First referee:

1)Name…………………………………………………………………………………………………………..

Address…………………………………………………………………………………………………………….

Post code…………………Email…………………………………………………………………………………

Tel………………………………………..Mobile:…………………………………......

Second referee:

2)Name…………………………………………………………………..………………………………………

Address………………………………………………………………..…………………………………………...

Post code…………………Email…………………………………………………………………………………

Tel ………………………....…………….Mobile:…………………………………......

REHABILITATION OF OFFENDERS ACT 1974

This post is exempt from the Rehabilitation of Offenders Act 1974. You are therefore required to declare any convictions including those which are “spent”. Failure to disclose any convictions may result in the immediate termination of your volunteer placement.

Have you ever been convicted of a criminal offence? (Please tick)

 YESNO

If yes, please seal the details in an envelope and return it with your application form. A conviction will not automatically debar you from placement. All information will be treated in the strictest confidence.

______

I declare the information given on this application form is true and complete

SIGNATURE……………………………………. DATE………………………………………….

The information you provide during the application process will, in the event of a successful application, be held on a secure database

CONFIDENTIAL HEALTH ASSESSMENT QUESTIONNAIRE FOR VOLUNTEERS

The purpose of this Health Assessment is to ensure as far as possible that you are fit for the role you plan to do and that your health and safety are not at risk.

Please answer YES or NO to all of the questions below. If you answer YES, please give further information in the spaces provided. Once completed, please place the questionnaire in a sealed envelope and return to the Voluntary Services Department along with your other forms. The form will not be opened by the Voluntary Services Department but passed unopened to the Occupational Health Department for processing.

Mr/Mrs/Ms Surname: / First name:
Male/Female / Date of Birth:
Address & home tel no.
Mobile tel no: Email address:
Proposed role:
This must be completed / Average hours per week:

Delete

/

Dates & details

1 / Are you currently receiving treatment of any kind from your GP, hospital specialist or other health practitioner or awaiting or undergoing investigations? If yes, please give details. / Yes/No
Do you experience any of the following:
2 / Any impairment, which may affect your ability to work safely? /

Yes/No

3 / Fits, blackouts or dizziness? / Yes/No
4 / Asthma, bronchitis or chest problems? / Yes/No
5 / In the last 12 months have you had a cough for more than
3 weeks, coughed up blood or had unexplained weight loss? / Yes/No
6 / Mental illness, depression, anxiety or stress? / Yes/No
7 / Diabetes or epilepsy? / Yes/No
8 / Heart disease/angina/high blood pressure? / Yes/No
9 / Eyesight problems not corrected with glasses or hearing problems? / Yes/No
10 / Skin problems/eczema/dermatitis? / Yes/No
11 / A health problem that causes you difficulty with mobility, sitting, standing, bending, lifting, carrying or working with a computer? / Yes/No
12 / Any other ongoing health problem or medical condition, not mentioned above? / Yes/No
13 / Are you taking any medication? If yes, please give details. / Yes/No

Space for further details, if required:

Declaration

1I declare that I have answered the above questions honestly and fully and that I am not otherwise aware of any physical or mental disability, which may affect my ability.

2I realise that if I falsely or knowingly withhold information relevant to this form, the Voluntary Services Manager will be informed of this fact. I realise that any false or incomplete statement may lead to termination of my Volunteer status.

3I consent to my health records being retained by Occupational Health and Wellbeing under the Data Protection Act 1998.

4I will update the Occupational Health and Wellbeing team if my medical situation changes between the time I complete this form and the time I commence my placement.

Signed: …………………………………………………………….. Date: …………………………

Print Name: …………………………………………………………………………………………..

If you have any difficulties in completing this form please contact Occupational Health and Wellbeing (01494 425082).

EQUAL OPPORTUNITIES MONITORING

As part of our commitment to providing equality of opportunity to all members of our community, we request that you provide the following information, although your application will not be prejudiced should you refuse to do so, and in no way forms part of the selection process. The information gained will be used solely for monitoring purposes and will be held on computer.

*Date of Birth
*Gender / MaleFemale
Transgendered Female (Male to Female)
 Transgendered male (Female to Male)
I do not wish todisclose this

Race relations (Amendment) Act 2000

As Public Sector Employers, NHS Organisations are required to collect details about an applicant’s ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.

* I would describe my ethnic origin as follows:
Asian or Asian British
Bangladeshi (K)
Indian (H)
Pakistani (J)
Any other Asian background (L)
Black or Black British
African (N)
Caribbean (M)
Any other Black background (O) / Mixed
White & Asian (F)
White & Black African (E)
White & Black Caribbean (D)
Any other mixed background(G)
White
British (A)
Irish (B)
Any other White background (C) / Other Ethnic Group
Chinese (R)
Any other ethnic group (S)
I do not wish to disclose my ethnic origin (Z)

Employment Equality Regulations

In order to comply with these regulations, NHS employers are monitoring sexual orientation and religion/belief in applications.

* Please select the option which best describes your sexuality
Lesbian
Gay
Bisexual / Heterosexual
I would rather not answer
* Please indicate you religion or belief
Atheism
Buddhism
Christianity
Islam / Jainism
Sikhism
Other / Judaism
Hinduism
I do not wish to disclose my religion/belief

Disability Discrimination Act 1995

Under the terms of the Act a disability is defined as a ‘physical or mental impairment which has a substantial and long term effect on a person’s ability to carry out normal day to day activities. The disability could be physical, sensory or mental and must be expected to last at least 12 months.”NHS employers welcome applications from disabled people.

* Do you consider yourself to have a disability? / Yes I do not wish to disclose this information
No
Please give details of your disability:
Data Protection Act
Buckinghamshire Healthcare NHS Trust needs your explicit consent to process this information. Please sign below to allow us to use it for diversity monitoring.Signature …………………………………………………………………………………………………… Date…………

Disclosure & Barring Service (DBS) Checks for volunteers

A criminal records check provides information about an individual's criminal record.All volunteers are required to have a DBS check before they start volunteering and a re-check every 3 years.

You will need access to a computer to complete an on-line application using the web address (below). Alternatively if you don’t have access to a computer we can arrange a time for you to use a computer in one of the voluntary services offices at Stoke Mandeville, Amersham or Wycombe Hospitals. Please let us know if you need assistance.

Please find below a list of the documents we can accept to support your Identification. Please bring original copies to your interview for verification of your Identity. NB. At least one document must show your current address and at least one document must show your date of birth. Please observe the issue dates for group 2b.

3 documents must be seen.

One document from Group 1 plus any two others from Group 1 or Group 2a or Group 2b

Group 1
Primary Trusted Identity Credentials
  • Current valid Passport
  • Biometric Residence Permit (UK)
  • Current Driving Licence (UK, Isle of Man /Channel Islands) (Full or provisional) A photo card is only valid if the individual presents it with the associated counterpart licence (except Jersey)
  • Birth Certificate (UK and Channel Islands) - issued at the time of birth; Full or short form acceptable including those issued by UK authorities overseas, such as Embassies, High Commissions and HM Forces. (Photocopies are not acceptable)
  • Adoption Certificate (UK and Channel Islands)

Group 2b *
Must have been Issued within last 3 months / Group2b **
Must have been Issued within last 12 months
Trusted Government/State Issued Documents
  • Current UK Driving licence (old style paper version)
  • Current Non-UK Photo Driving Licence (valid only for applicants residing outside of the UK at time of application)
  • Birth Certificate (UK and Channel Islands) - (issued after the time of birth by the General Register Office/relevant authority i.e. Registrars – Photocopies are not acceptable)
  • Marriage/Civil Partnership Certificate (UK and Channel Islands)
  • Adoption Certificate (UK and Channel Islands)
  • HM Forces ID Card (UK)
  • Fire Arms Licence (UK and Channel Islands)
/ Financial/Social History Documents
  • Bank/Building Society Statement (UK or EEA)* (Non-EEA statements must not be accepted)
  • Bank/Building Society Account Opening Confirmation Letter (UK)
  • Credit Card Statement (UK or EEA)* (Non-EEA statements must not be accepted)
  • Utility Bill (UK)* – Not Mobile Telephone
  • Benefit Statement* - e.g. Child Allowance, Pension
  • A document from Central/ Local Government/ Government Agency/ Local Authority giving entitlement (UK & Channel Islands)*- e.g. from the Department for Work and Pensions, the Employment Service , Customs & Revenue, Job Centre, Job Centre Plus, Social Security
  • EU National ID Card
  • Cards carrying the PASS accreditation logo (UK and Channel Islands)
  • Letter from Head Teacher or College Principal (17 year olds in full time education – (only used in exceptional circumstances when all other documents have been exhausted)
/ Financial/Social History Documents
  • Mortgage Statement (UK or EEA)** (Non-EEA statements must not be accepted)
  • Financial Statement ** - e.g. pension, endowment, ISA (UK)
  • P45/P60 Statement **(UK & Channel Islands)
  • Council Tax Statement (UK & Channel Islands) **
  • Work Permit/Visa (UK) (UK Residence Permit) **