Name:* Have you ever received First Aid or Disaster Training? Yes No 1. 2. Training Type: Approximate Date (Year): 3. Would you like to attend 1st Aid/CPR/AED training or refresher course? Initial Training Refresher Course Healthcare provider course Do you have a family disaster plan? Yes No 4. Does your plan include arrangments for child/senior care? Yes No 5. Would you be interested in attending optional training on: bioterrorism smallpox vacinations community disaster/emergency response disaster mental health counseling emergency communications advanced incident/unified command chemical/nuclear exposure cultural competence/risk communications professional certification/updates for CEU or CME credit 6. Are you actively involved as a disaster response volunteer? Yes No Please list agencies or organizations and possible conflicts: 7. Would you be available to participate in possible annual or
semi-annual Medical Reserve Corps volunteer training?
Yes No 8. Would you be interested in participating in: An emergency response tabletop exercise? A live participation community exercise or drill? 9. Would you need any reasonable accommodations in order
to participate in the Medical Reserve Corps:
Yes No What would you require? 10. Do you prefer to: Work independently Work in a team/group setting No preference 11. Do you have leadership or management experience? Yes No Please describe: Would you be comfortable in a leadership role? Yes No 12. Do you have experience working with special needs populations? Yes No 13. Please explain: Do you have special skills or experience that would be helpful
in the event of a disaster?
Yes No 14. Triage Emergency department Medical history taking Bi/multi-lingual Administering injectible medicines/vaccines Post disaster counsleing Health care of children Teaching Others If Others, please explain: 15. Do you have previous experience administering vaccinations? Yes No What is the best way to contact you? Email Phone Fax 16. U.S. Mail Please provide your email address: Please provide your phone number: Please provide your fax number: Please provide your mailing address: If you would like to receive MRC newsletters, updates and training
opportunities by email, please provide your preferred email address:
17. Do you give permission for use to provide your email address to partner
agencies, such as United Way, Red Cross, Salvation Army, etc., regarding
other volunteer opportunities in our area?
Yes No 18.