PICCE Intake Form New PICCE Intake Form PICCE Intake Form Please take your time to fill out this information as accurately as possible. It's a long form but it helps us to get a better of who your organization is and what you're about. Once you've completed the form a member of PICCE will reach out to your organization! Organization Name * Organization Website/URL Organization Address * Organization Address Organization Address Organization Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Contact Name * Primary Contact Title * What is the job title of the primary point of contact? Primary Contact Phone Number * (123)456-7890 Primary Contact Email Address * Secondary Contact Name * Secondary Contact Title Secondary Contact Phone Number (123)456-7890 Secondary Contact Email Address Describe any requirements or restrictions for student volunteers * e.g. age requirement, background check, application, Covid restrictions, food handlers permits etc. Briefly describe your mission * What are your organization's days and hours of operation? What is your organization's tax classification? * 501(c)(3) 501 (c)(4) OtherOther check all that apply Give an overview of the need in your organization that you believe could be met by university students * e.g. service opportunities, projects, research, etc. Please select all of the different types of supports that your organization could utilize. Option 1 Option 2 Does the organization offer an orientation/training program for new volunteers and Service-Learning students? * Yes No Is the training/orientation program required? * Yes No Please describe the training/orientation program both in terms of content and logistics Timeline,l frequency, and the required length of training. Please upload any documents relevant to the trainings Drop a file here or click to upload Choose File Maximum file size: 268.44MB Is there a minimum age requirement for volunteers? * Yes No Do you have a minimum number of hours required by volunteers? * Yes No What is the minimum age? How many hours do you require? Does the agency require background checks? * Yes No Who pays for the background check? The organization The volunteer Not applicable What types of background checks are required? Washington State Background Check National Background Check FBI Fingerprinting Not Applicable What types of volunteers can you accommodate? * Groups (clubs, sororities/fraternities, Days of Service, Alumni Individual Volunteers Service Learning Students Interns College/University Staff and Faculty OtherOther For group volunteers, what is your maximum capacity? From the following list, please note if you have the following features at your service site by checking all that apply: * A single point of entry (main entrance) with any periphery doors locked ADA Compliant Accessible Spaces ADA Accessible bathrooms Adequate outdoor lighting CCTV/AV Recording On site parking Security staff Locked space for volunteer personal items Written visitor policy Visitor and volunteer badges First aid kits on site Fire extinguishers Fire alarms AED Defibrillator Marked exits PA system Posted emergency contacts Bathrooms on site Gender Neutral Restrooms Carbon Monoxide detectors CPR trained staff Staff background checked Staff receive anti-sexual harassment training Incident reporting procedures (responses to these questions will not automatically qualify or disqualify you from partnership) Does your organization have liability insurance that covers volunteers? * Yes No Does your agency carry other forms of insurance relevant to volunteers? * Yes No Please upload proof of insurance if available. Drop a file here or click to upload Choose File Maximum file size: 268.44MB Please describe any site-specific security/risk management features your organization has in place. * Is there anything else we should know about your agency? Intake Checklist Dropdown Option 1 If you are human, leave this field blank.
