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In the event
of a large scale public health emergency affecting our
community, medical and non-medical volunteers will be
needed to help with the public health response. Plans
are in place to respond rapidly to a public health
emergency with Federal, State and County resources. Our
community needs people to execute these plans. Clinics
may be needed to triage citizens, provide medical
supplies and medicines. Will you be a part of the call
list to help our community should we be faced with a
large scale public health emergency?
Yes, I
____________________________________________________will
volunteer my services should our community be faced with
a large scale public health emergency.
____ I am over 18 years of age.
____ I have no felony convictions for D.W.I.,
drug-related, sexual, or family violence offences.
Drivers License #_________________________ State_______
Expiration date___________________
Are you willing to assume a role of authority? Yes
_________ No __________
MEDICAL
VOLUNTEER ( LICENSE WILL BE VERIFIED)
Physician: MD DO
Nurse: RN LVN
License
#/State_________________________ License#/State_________________________
Physician’s Assistant
Nurse
Practitioner:
License #/State _________________________
License #/State ________________________
Student
Nurse: Level I Level II
Pharmacist:
School Attending
______________________ License
#/State________________________
Paramedic/EMT:
Respiratory
Therapist:
Certification #/State ____________________
License #/State ________________________
NON-MEDICAL VOLUNTEER
Occupation:___________________________________________________________________
Special
Skills:
__________________________________________________________________
__________________________________________________________________
Licensed
to Drive School Bus: Yes No
Languages other than English spoken:
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