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Disaster Recovery-Medical Mission Volunteer Form
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1.
What's your full name (First name, Last Name)?
(Required.)
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2.
What phone number best to contact you?
(Required.)
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3.
The phone number I provided is my?
(Required.)
Mobile number
Home number
Work number
Other (please specify)
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4.
What is your personal email address?
(Required.)
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5.
What facility do you currently work at? (Your employer)
(Required.)
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6.
What language/s do you speak besides English, if any?
(Required.)
Spanish
French
Dutch
Haitian Creole
Papiamento
Portuguese
Tagalog
Chinese
Korean
Japanese
Vietnamese
Other (please specify)
7.
What country or area do you want to volunteer to?
8.
If you answer the question #7 what is your reason?
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9.
What age range do you belong to?
(Required.)
<30 years old
30 - 40 years old
41 - 50 years old
51 - 60 years old
>60 years old
Decline to state
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10.
If called to volunteer, how many days notice do you need?
(Required.)
Less than 24 hours
1-2 days
3-4 days
5-7 days
Other (please specify)
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11.
What is your specialty?
(Required.)
Emergency/Trauma
Medical
Surgical
Psychiatry
Cardiac Stepdown
Critical Care
Education/Clinical Nurse Specialist
Pediatrics
Neonatal Care
OB/Gyn
Other (please specify)
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12.
Have you volunteered in disaster relief/ medical missions in the past?
(Required.)
Yes
No, this will be my first time
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13.
Are you a member of NYSNA?
(Required.)
Yes
Non-union
No but I belong to another union
Other (please specify)
