Mountain States Health Alliance | Faculty Reference Form

Faculty Reference Form

Faculty Reference Form for Students applying in the Volunteer Program.

Full Name: *

Email Address: *

Academic Institution: *

Street Address: *

City: *

State: *

Zip: *

Phone: *

Name of Student Volunteer: *

There are many opportunities at MSHA for students to gain valuable experience by providing an up close look at a healthcare profession in a secure and controlled environment.

In order for MSHA to ensure proper placement of this student, please check the box with the appropriate type of experience the student is to obtain:

Type of Experience Recommended for Student:

The student volunteer experience at MSHA allows prospective and current students the opportunity to develop interests in a healtcare field or learn about an already chosen area of study.
The students are scheduled into existing volunteer programs set up in numerous areas of the healthcare system. Volunteers learn in a hands on environment according to their volunteer service description for that area.
Volunteering at MSHA is a great waty to accomplish community service obligations for a particular class requirement. Questions? Contact the Volunteer Services Supervisor @ (423)431-3543 or email Volunteers@msha.com.

Type of Experience Recommended for Student:

Job Shadowing

Students can job shadow any time in any area of their choice to help determine a career path
Job shadowing is a "no hands on" learning experience - observation only
All students must be affiliated with a school and sign an individual observation agreement before participating in the job shadwoing experience.
For this type of experience, the contact person is the Education Program Specialist (423)431-1673. Contact must be made prior to the experience.

Type of Experience Recommended for Student:

Internship

MSHA welcomes students to participate as an intern to gain experience in any area of healthcare which they have chosen as a career path.
Internships allow students to participate in hands-on learning focused on the duties of the employee/career. This is accomplished while paired with an individual preceptor or under the supervision of their instructor.
Internships are for students who are required to complete a set amount of hours in one particular are as required by their program of study.
School instructors must submit the internship requirements to the Education Program Specialist for placement with a preceptor/mentor. Any affiliate student wishing to complete an internship at MSHA must contact the Education Program Specialist @ (423)431-1673 to set up the internship experience.

Please rate the following characterstices using a 1 to 5 rating with 5 being the highest

Positive Attitude:

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2
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4
5

Honest/Trustworthy:

1
2
3
4
5

Dependable:

1
2
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4
5

Compassionate:

1
2
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4
5

How long have you known this student? *

In what capacity have you know this student?

Why do you think this student would make a good volunteer?

Would you like more information about MSHA volunteer Programs?

Yes
No

Clicking the send button is your electronic signature stating that the information you have submitted is correct!