2024 BRG SORT Healthcare/Medical Volunteer Hours Verification Form
Each student completing the application process for the 2024 Application Year (Jan 2025 Start) is required to complete 40 hours of healthcare or medical VOLUNTEER hours within any facility of the student's choice and the organization/site's approval from Jan 2024 to August 2024. For verification that this requirement to be completed appropriately for admissions, the student must get this verification form completed at the conclusion of a minimum of 40 hours. This form serves also serves as an evaluation of the volunteer time of the prospective student for a future in the healthcare profession that they are choosing. THESE MUST BE VOLUNTEER or UNPAID hours.
 
Examples of this can be: urgent care, primary care, hospital, therapy, pediatric clinic, nursing home, committee of an event benefitting a medical or healthcare cause (Alzheimer's, Ped Developmental Disabilities, Heart Walk, etc.), veterans clinic, medical office, dental, veterinary clinic, etc. Approval from the program may be obtained for anything outside of this can be emailed to the address below.

The student officially waives the right to view this form when requesting you to submit for verification. Your response will only be viewed by the Program Registrar, Program Director, and the admissions committee as needed for selection for the Class of 2026.

Please complete and select "Submit" when you are ready. The BRG SORT Program Director for more information or clarification if needed at the contact provided.

Thank you for assisting us in this process. Please email Lan618@brgeneral.org with any questions or comments.
BRG SORT Administration and Admissions
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Email *
Name of Applicant: *
Number of Hours completed under my direction:
 *
Name of Verification Individual, Credentials, Title with Facility/Event/Organization
 *
Organization/Facility Name, Mailing Address Or Location of Event Taking Place/Date
 *
Contact Phone for Verification Individual:
 *
Personal Characteristics: Comparing the Applicant to others of similar background or experience, Please rate the Applicant in EACH of the categories below WHEN COMPLETING VOLUNTEER HOURS with you:
 *
Not Appropriate; Have Concerns
Appropriate
Exceeds Peers in Appropriateness
Speech (Oral Communication) and Decorum (Social Engagement/Behavior)
Grooming and Personal Hygiene
Level of Maturity/ Self Awareness
Personal Responsibility/Accountability
Promptness/Meeting Deadlines
Absenteeism/Cancellation/Reschedule
Overall Ability toward Completion of Given Task
How did the applicant receive assertive instruction, direct corrective feedback, or respond when changes in behavior or skills are needed? Feel Free to provide an example.
 *
Performance Characteristics: Comparing the Applicant to others of similar background or experience, Please rate the Applicant in EACH of the categories below WHEN COMPLETING VOLUNTEER HOURS with you:
 *
Inadequate
Below Average, Meets minimum
Average
Above Average
Excellent, Top Performer
Quality of Work
Quantity of Work
Organization or Structure of Work
Written Communication
Learning Skill/Ability to Learn New Things
Ability to Retain Skills Learned and Build on those
Ability to work well with others/In Team Environment
Flexibility/Ability to Deal with Change
Initiative/Self-Directed/Resourceful
Ability to Deal with Stress
Time Management/Task Management under deadline
Critical Thinking Skills/Ability to adapt
Ability to Handle Feedback/Constructive Criticism
Ability to Assess Information Given and Perform Quickly and Efficiently
How did the applicant do in problem solving and critical thinking situations? Can they adjust and be resourceful independently? Feel free to provide an example.
 *
How did the applicant work/perform in stressful or changing environments with moderate demands on time or multitasking? Feel free to provide an example.
 *
When completing the healthcare or medical volunteer hours with you, how would you rate this Applicant for admissions into a rigorous professional program for Medical Imaging/Healthcare?
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Not Well/Concerns for Long Term Success or Patient Safety
Exceptionally Well, No concerns Long Term or with Patient Safety
Did the applicant complete the volunteer hours as you expected and in the time frame given by your or your organization?
 *
No, Would Not Have Back/ Less than minimum
Yes, Completed Better than Expected/ Would Ask for their Help again
Verification Authorization Statement: 

I verify that the above mentioned and evaluated student completed the hours as mentioned under my direction as stated within my organization or facility. 

To sign, please type your Legal Name and Today's date.
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Submit
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