Volunteer telephone buddy - Application Form

Application to be a telephone buddy - Covid 19 crisis

Thank you for applying to be a volunteer with Healthwatch North East Lincolnshire.

In support of the community effort to help local people during the COVID-19 crisis we are encouraging people to get involved with volunteering to help in any way they can to support our communities through this difficult time.

By applying for this role you are committing to offering telephone buddy support for members of your local community.

What will you be doing?

We would ask that you maintain a level of contact with the person on an agreed timescale depending on the person’s needs or wishes. During these calls you could chat to them about:

· the current situation, ensuring they have the most up to date information, and are reassured and not frightened by current events

· ask if they are in need of anything and signpost them to any relevant support services

· suggest ways for them to maintain good health and wellbeing at this time

· help them to maintain their connection to the world – chatting about all the other things that are going on – COVID-19 is not the only talking point

-ask about hobbies and interests

We ask you to complete this application form so that we can assess your suitability as a volunteer and to learn about the skills and experiences you have to help us in our work, and to match you with a member of the public who may need your support.

Please tell us as much as you can about yourself.

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* 1. Please complete the following

Name -

Age -

Email address -

Address-

Postcode-

Landline phone number-

Mobile phone number-

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* 2. What is your current occupation?

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* 3. Do you have any special requirements to carry out a volunteer role which we should be aware of? Please highlight any support, adaptations, or equipment you may require from us.

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* 4. Why do you want to volunteer with Healthwatch North East Lincolnshire?

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* 5. Why are you interested in the role of covid -19 volunteer telephone buddy? Please refer to job role

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* 6. What are you hoping to achieve from this role?

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* 7. Please write down any information that you feel would be relevant to your application. This could include details of
-previous voluntary work undertaken,
-details of any skills you feel you are able to bring to Healthwatch
-relevant work experience,
-personal qualities
-qualifications or courses that you feel would be relevant.

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* 8. Can you speak more than one language ? If yes please specify

Yes

If yes (please specify)

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* 9. What do you enjoy doing in your spare time? please outline any hobbies or interests that you have.

Reading

Watching TV

Fishing

Gardening

Films

Exercise

Music

Crafts

Playing cards

Cooking

Painting

Sewing

Knitting/Crochet

Theatre

Sports

Dancing

Animals

Writing

Other (please specify)

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* 10. Availability: Please let us know your availability to volunteer for us. We have no set amount of time you need to commit to this, you can commit to as many or as little hours/ days that you wish.

	Morning (9-12)	Afternoon (12-5)	Evening (5-8)
Tuesday	Tuesday Morning (9-12)	Tuesday Afternoon (12-5)	Tuesday Evening (5-8)
Wednesday	Wednesday Morning (9-12)	Wednesday Afternoon (12-5)	Wednesday Evening (5-8)
Thursday	Thursday Morning (9-12)	Thursday Afternoon (12-5)	Thursday Evening (5-8)
Friday	Friday Morning (9-12)	Friday Afternoon (12-5)	Friday Evening (5-8)
Saturday	Saturday Morning (9-12)	Saturday Afternoon (12-5)	Saturday Evening (5-8)
Sunday	Sunday Morning (9-12)	Sunday Afternoon (12-5)	Sunday Evening (5-8)

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* 11. Please declare any other roles which may be a potential conflict of interest and which may cause problems for you (for example if you are a local Councillor).

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* 12. Have you ever been convicted of a criminal offence?

yes

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* 13. Do you have an up to date DBS certificate?

Yes

Not sure

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* 14. If yes - What date was the DBS completed?

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* 15. Are you aware of any changes to your DBS since this date ?

Yes (please comment below)

Not sure (we can discuss this over the phone)

please specify changes (incl dates)

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* 16. Are you able to provide evidence of your DBS?

Yes

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* 17. In support of your application, we will need to contact two people who would be able to provide a reference for you over the phone or via email. Are you happy to do this ? (if yes we will collect reference details at a later date)

Yes

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* 18. Declaration
The information in this application is true and accurate. I understand that any failure to declare relevant information or to provide false information could result in my application being rejected and my volunteer role being withdrawn.

Yes i agree to the declaration above

No i do not agree

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* 19. If appointed, I agree to abide by the requirements for good volunteer conduct; follow relevant Healthwatch policies; and act in the best interests of Healthwatch North East Lincolnshire.

Yes i agree

No I do not agree

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* 20. I understand and agree that, as part of volunteering for Healthwatch North East Lincolnshire, my details will be held in a confidential database that will only be used for reasons relating to my volunteering and this form will be filed in my confidential personnel file. All information about me will be held in accordance with the Data Protection Act 1998.

Yes i agree

No I do not agree

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* 21. Are you happy for us to pass your details on to other organisations which may have more suitable volunteering opportunities? (We would discuss this with you beforehand)

Yes

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* 22. How would you like us to contact you ?

landline telephone

mobile telephone

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* 23. How did you hear about this opportunity ?

Website

Facebook

Twitter

Instagram

Through my employer (part of workplace health scheme)

Word of mouth

'Do it'website

Other (please specify)

Thank you for taking time to complete this application.
You are truly amazing!
We will contact you shortly to discuss the next steps and to match you with a local person in need of support.

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* 24. OFFICE USE ONLY

INFORMAL PHONE INTERVIEW COMPLETED

ID CHECKED

DBS VALIDATED

DBS PROCESS STARTED

DBS PROCESS COMPLETED

VOLUNTEER ACCEPTED

VOLUNTEER NOT ACCEPTED - VOLUNTEER INFORMED

BUDDY PACK SENT

VOLUNTEER MATCHED WITH SERVICE USER (IF YES NAME OF SERVICE USER BELOW)

NAME OF SERVICE USER

Volunteer telephone buddy - Application Form

Application to be a telephone buddy - Covid 19 crisis

Question Title

* 1. Please complete the following

Question Title

* 2. What is your current occupation?

Question Title

* 3. Do you have any special requirements to carry out a volunteer role which we should be aware of? Please highlight any support, adaptations, or equipment you may require from us.

Question Title

* 4. Why do you want to volunteer with Healthwatch North East Lincolnshire?

Question Title

* 5. Why are you interested in the role of covid -19 volunteer telephone buddy? Please refer to job role

Question Title

* 6. What are you hoping to achieve from this role?

Question Title

Question Title

* 8. Can you speak more than one language ? If yes please specify

Question Title

* 9. What do you enjoy doing in your spare time? please outline any hobbies or interests that you have.

Question Title

* 10. Availability: Please let us know your availability to volunteer for us. We have no set amount of time you need to commit to this, you can commit to as many or as little hours/ days that you wish.

Question Title

* 11. Please declare any other roles which may be a potential conflict of interest and which may cause problems for you (for example if you are a local Councillor).

Question Title

* 12. Have you ever been convicted of a criminal offence?

Question Title

* 13. Do you have an up to date DBS certificate?

Question Title

* 14. If yes - What date was the DBS completed?

Question Title

* 15. Are you aware of any changes to your DBS since this date ?

Question Title

* 16. Are you able to provide evidence of your DBS?

Question Title

* 17. In support of your application, we will need to contact two people who would be able to provide a reference for you over the phone or via email. Are you happy to do this ? (if yes we will collect reference details at a later date)

Question Title

* 18. DeclarationThe information in this application is true and accurate. I understand that any failure to declare relevant information or to provide false information could result in my application being rejected and my volunteer role being withdrawn.

Question Title

* 19. If appointed, I agree to abide by the requirements for good volunteer conduct; follow relevant Healthwatch policies; and act in the best interests of Healthwatch North East Lincolnshire.

Question Title

Question Title

* 21. Are you happy for us to pass your details on to other organisations which may have more suitable volunteering opportunities? (We would discuss this with you beforehand)

Question Title

* 22. How would you like us to contact you ?

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* 23. How did you hear about this opportunity ?

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* 24. OFFICE USE ONLY

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* 25. NOTES (further info)

* 18. Declaration
The information in this application is true and accurate. I understand that any failure to declare relevant information or to provide false information could result in my application being rejected and my volunteer role being withdrawn.