NJHC - New Jersey Health Care Professional Registry

 


State of New Jersey Medical Reserve Corps
New Jersey Department of Health

Community Health Volunteer Application

MORRIS COUNTY MEDICAL RESERVE CORPS

Date of Application (mm/dd/yyyy)

Personal Information
Last Name

First Name
Middle Name
Nickname
Date of Birth (mm/dd/yyyy)

Street Address

City
County
State:
Zip
Mailing Address (if different)

City
State
Zip
Note: Please enter at least one Phone No.
Home Phone Number:
- -
Home Fax Number:
- -
Cell Phone Number
- -
Pager Number
- -
Provide the e-mail where you want to receive messages

 
Do you possess a valid driver's license?  Yes       No
Driver's License Number

Expiration Date
Class
  
State:


Employment Information
Place of Employment

Work Address

City
    
State
Zip
Work Phone Number
- - Extn
 

Emergency Contact - Will be notified in case of an emergency.
Last Name

First Name
Relationship
Street Address

City
    
State
Zip
Note: Please enter at least one Phone No.
Home Phone Number
- -
Work Phone Number
- - Extn
Cell Phone Number
- -
Pager Number
- -


Additional Information
Language: Fluent? Speak? Read? Write?
 
Question
Yes    No
Comment
Are you willing to travel and volunteer outside of your county?     
Are you willing to participate in a Federally coordinated emergency response?     
Willing to provide translation service?     
Do you have ability to communicate using sign language?     
Have you been immunized against Smallpox?     
Year of most recent smallpox vaccination
Do you have any special needs or restrictions? If so, please explain.     
Are you committed to any other organization or institution, by virtue of employment or volunteerism, in the event of a public health emergency? If yes, explain.     
Do you have particular expertise and agree to be available for consultation or response throughout the state?     


Experience: Do you have any of the following skills?
  CPR   Language Interpretation
  Clerical Work   Loading/Shipping
  Computer Networking   Lodging Services
  Computer Skills   Managerial Services
  Counseling Skills   Office Management
  Crowd Management   Phone Receptionist
  Data Entry   Retired Nurse
  Desk Top Support   Retired Other Health Care Professional
  Elderly / Disabled assist.   Retired Physician
  Facility Management   Search / Rescue
  First Aid   Social Work
  Food Services   Specialty
  Interviewing   Transportation
  Inventory Supplies/Equipment   Volunteer Services

Training/Continuing Education
Have you completed any training or continuing education programs in the following areas? If so, please check.
  Advanced Cardiac Life Support (ACLS)   Hazardous Materials Training (HAZMAT) Biological
  Advanced Trauma Life Support (ATLS)   Hospital Preparedness
  Basic Cardiac Life Support (BLS)   Incident Command Training (ICS)
  Basic Disaster Life Support (BDLS)   Isolation and Quarantine
  Bloodborne Pathogens   Mental Health Training for Disasters
  CBRNE Training   Pediatric Advanced Life Support (PALS)
  Citizen Emergency Response Team (CERT) Training   Triage
  CPR/AED   Vaccination administration smallpox
  Exercise design and evaluation   Vaccination administration
  First Aid   Venipuncture
  Fit Testing for Particulate Respirators   Weapons of Mass Destruction (WMD) Training


Expectations of NJ Medical Reserve Corps Community Health Volunteers

As a volunteer with the New Jersey Medical Reserve Corps, I will be called upon to assist in the event of a public health emergency. I agree to attend an educational program to explain my role in disaster preparedness; I will be assigned duties based on my level of training and experience. I understand that submitting this application does not guarantee acceptence into the NJ Medical Reserve Corps. The information contained in this application is, to the best of my knowledge, truthful. I agree to serve my fellow citizens to the best of my ability.


I Agree to the above statement
Failure to agree to the above statement invalidates application.



     

Required Field
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