Credentialed Volunteer Vaccinator Form

If you are a provider credentialed by the NHRMC Medical Staff Office with an active North Carolina license, please complete the following forms and someone from the Medical Staff Office will contact you.


Position Title: Volunteer Vaccination Clinician

Department: Volunteer Services

Responsible to: Director, Volunteer Services, Site Manager, Shift Lead

Effective Date: January 15, 2021


All duties outlined within this document should be performed according to established policies and procedures of New Hanover Regional Medical Center. Volunteer clinicians may work within the guidelines of the scope of their professional role as defined by the State of North Carolina or the accrediting professional organization.

Example vaccinator may include: RN, LPN, Paramedic, EMT/AEMT, Medical Assistant, Physician, Physician Assistant, Nurse Practitioner, Pharmacists, Dentists, Veterinarians.


  1. Demonstrate the mission of NHRMC- Leading Our Community to Outstanding Health and uphold the four values of the medical center- Ownership, Teamwork, Communication and Compassion.
  2. Volunteers must adhere to HIPAA’s policy to protect the patient’s right to privacy.
  3. Follow infection control guidelines to protect the safety of volunteers, staff, patients and community.
  4. Administers vaccination to patients/clients using Standard Precaution and guidelines set forth for the safe administration of vaccines.
  5. Refills supplies at workstation and at end of shift and as needed.
  6. Sanitizes table and chairs as needed.
  7. Provide emotional support to patient and family members.
  8. DO NOT lift patients without assistance.
  9. Documents patient information and administration of vaccination.
  10. Provides hand-off communication to oncoming relief staff, and/or to manager in charge of work unit.
  11. May take vital signs if needed.
  12. Work at least a 6-hour shift.
  13. Complete any required education relate to the role initially and ongoing.



Volunteer Position Description: Volunteer Vaccination Clinician


  1. Education: Minimum requirement: Licensure, certification or qualification to provide intramuscular injection for the purposes of vaccination. Must provide documentation requested validating licensure, certification, or qualification.
  2. Experience: Health care setting is mandatory.
  3. Interpersonal Skills: Good communication skills. Ability to interact well with patients, families and staff. Passionate about the health of the community.
  4. Essential Technical/Motor Skills: Must be able to record information accurately. Ability to administer vaccines.
  5. Essential Physical Requirements: Must be able to move throughout the vaccination site. Ability to lift 10-15 lbs. Must be able to wear a mask, or other required personal protective equipment, the entire length of the shift.
  6. Essential Mental Abilities: Ability to perceive patient’s needs. Ability to listen and follow instructions, ability to assess patients and relate information to other healthcare team members.
  7. Essential Sensory Requirements: Visual acuity and able to hear in a noisy setting to carry out role.
  8. Exposure to Hazards: minimal
  9. Hours of Work: Hours vary based on needs.
  10. Age Specific: Must be 18 or older
  11. Populations Served: All populations including hospital staff, physicians and the public.
  12. Length of Commitment: Must be able to commit to one 6-hour shifts
  13. Training: Training consists of one initial module. Additional training will be arranged if required.

volunteer my time and clinical skills to assist in this declared emergency disaster. I UNDERSTAND THIS IS VOLUNTARY AND I WILL RECEIVE NO COMPENSATION FOR ASSISTING.

and provide my license/certificate/registration number below:

I further understand that I will assist under the direction of the charge person and will be responsible to function only in my area of expertise/licensure/scope of practice.

I understand that I must always wear the official NHRMC and Affiliates identification badge when on any of the NHRMC and Affiliates campuses.

Entering your name and date in the signature field below constitutes your signature and acceptance.