UCSF HUMAN RESOURCES
DISABILITY MANAGEMENT SERVICES
WORKERS' COMPENSATION UNIT
FAX (415) 476-2328; BOX 0964

UCSF VOLUNTEER SERVICE AGREEMENT FORM (For use with Staff Level Volunteers)

** This form should be developed on Department letterhead **

  Volunteer:  Name __________________________________________________

               Address _______________________________________________

               Telephone _____________________________________________

               Social Security Number ________________________________

1.  Assignment is for the ____________________________________________
                                       (School/Department)

2.  School/Department:  Name _________________________________________

                        Address ______________________________________

                        Phone ________________________________________

3.  Direct Supervisor will be ________________________________________ 
                                         (Name & Title)

                        Phone ______________________________

4.  Beginning and End Dates __________________________________________
    (Be specific, please. End date can be extended later)

5.  Schedule of Volunteer Hours: (e.g.,  M-W-F  9 a.m. to 12 p.m.)

         _____________________________________________________________

6.  Volunteer Duties/Responsibilities: List
    (Note: No patient procedures are to be performed by the volunteer)

         _____________________________________________________________

         _____________________________________________________________

         _____________________________________________________________

         _____________________________________________________________

7.  Physical Demands/Requirements include ____________________________

         _____________________________________________________________

         _____________________________________________________________

         _____________________________________________________________

8.  Special Skills: List (e.g. languages, software applications, typing,
    etc.) ____________________________________________________________

          ____________________________________________________________

9.  Emergency contact:  Name ____________________________________

                        Telephone _______________________________

10. Library use permitted? ______________________________________
    (Level of use must have been agreed to by Library Circulation
    Supervisor at 476-5579)

11. If volunteer is a licensed professional, a copy of current certifi-
    cate of professional liability insurance must be attached. (Note:
    No patient procedures are to be performed by the volunteer)

12. Special immunizations needed, i.e. Hepatitis, TB, etc. ___________

       _______________________________________________________________
       (Records should be attached)

13. Volunteer Election of Workers' Compensation Coverage form: Read,
    sign and attach.

14. If a minor, volunteer must apply a signed Parental Consent For
    Minor Volunteer form, and this should be attached.

15. Signature and title of volunteer's supervisor(s) responsible 
    for training and supervision of volunteer:

       _______________________________________________________________
       Signature                                Title

       _______________________________________________________________
       Signature                                Title

       _______________________________________________________________
       Signature                                Title

    Signature and title of Volunteer in agreement with services:

       _______________________________________________________________
       Signature                                Date

    Signature and Title of Department Personnel Representative:

       _______________________________________________________________
       Signature                Title                             Date

FORM DISTRIBUTION:
FAX A COPY OF THE COMPLETED FORM TO THE HUMAN RESOURCES WORKERS' COMPENSATION UNIT OF DISABILITY MANAGEMENT SERVICES. GIVE THE ORIGINAL FORM TO YOUR DEPARTMENT'S PERSONNEL REPRESENTATIVE TO BE FILED IN THE VOLUNTEER'S PERSONNEL FILE.

RETAIN VOLUNEER RECORDS FOR AT LEAST 18 MONTHS FOLLOWING TERMINATION OF VOLUNTEER SERVICES.

UCSF HUMAN RESOURCES - DISABILITY MANAGEMENT SERVICES DIVISION - WORKERS' COMPENSATION UNIT