Volunteer Health Information Form Page 3
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Name
Relationship
Address
City
State
Zip Code
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Daytime Phone Number (
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Evening Phone Number (
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Please check off your preferred tasks during an emergency:
Assist clients with forms
Evidence preservation
Mental Health
Assist with client education
Evacuation
MRDD Services
Assist with flu clinics
Greeter
Registration
Assist with health screenings
Ham Radio Operator
Security/Law Enforcement
Computer Support
Immunizations
Supply/Stock
Data entry
Infectious Disease/Contact Tracing
Strategic
National Stockpile
Decontamination
Interpreter Services
Surveillance
Education and training
Injured or deceased animals
Trauma
Environmental health
Laboratory capacity
Triage
Other, please describe
Yes
No
Do you speak or read a language other than English?
If so which one?
Yes
No
Do you have any disaster/emergency response experience?
If so, describe
Yes
No
Do you have any public health response experience?
If so, describe
Yes
No
Do you have any disaster or crisis training or experience?
If so, describe
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Please check all current training or volunteer opportunities that apply:
Advanced Disaster Life Support (ADLS)
American Red Cross
Advanced Trauma Life Support (ATLS)
Disaster Medical Assistance Team
Basic Cardiac Life Support (BCLS)
Disaster Mortuary Operational Response Team
Basic Disaster Life Support (BDLS)
Basic First Aid
CERT training
Cardiopulmonary Resuscitation (CPR)
Critical Incident Stress Debriefing (CISD)
Hazmat Awareness Level training
Incident Command Structure (ICS)
Pediatric Life Support (PALS)
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