Delaware Health and Social Services Division of Public Health Public Health Preparedness Section 100 Sunnyside Road Smyrna, DE 19977 Phone: (302) 223-1720 Fax: (302) 223-1724 Delaware Medical Reserve Corps Application 1. Contact Information: First Name: Middle Name: Last Name: Gender: 0 M 0 F Home Address: City: State: DE Zip Code: Mailing Address: (if different from above) City: State: DE Zip Code: County you live in: County you work in: Home Phone Number: - - Cell Phone Number: - - Work Phone Number: - - Pager Number: - - Primary Email Address: Alternate Email Address: Date of birth: month/day/year / / Driver’s License / ID No: (state) (number) 2. What is the best way to contact you in the event of an emergency? 2a. Primary contact: 0 Home Phone 0 Cell Phone 0 Pager 0 Email 2b. Secondary contact: 0 Home Phone 0 Cell Phone 0 Pager 0 Email 3. Do you have any military service obligations in the event of an emergency? 0 Yes 0 No If yes, please explain what they are (maximum 200 characters allowed) 4. Do you have any other commitments that might pose a problem in case of an emergency? 0 Yes 0 No If yes, please identify: Red Cross: 0 Hospital / Clinic: 0 (insert facility name) First Responder: 0 Fire Service 0 Law Enforcement 0 EMS 0 Haz Mat Other: 5. What is your employment status? 0 Full Time 0 Part Time 0 On Call 0 Not Employed 0 Retired 0 Student 6. Do you work at more than one location? 0 Yes 0 No 7. In what type of setting do you work? Health Care Settings: 0 Clinic 0 Home Care/Hospice 0 EMS Provider 0 Laboratory 0 Assisted Living 0 Nursing Home 0 Rehabilitation 0 Pharmacy 0 Physician Practice: (please specify specialty) 0 Other: (please specify) Hospital Settings: 0 Emergency Room 0 Intensive Care 0 Medical/Surgical 0 Laboratory 0 X-ray 0 Other diagnostic procedures: (please specify) 0 OB/GYN 0 Operating Room/Recovery Room 0 Pediatrics 0 Rehabilitation 0 Pharmacy 0 Psychiatric / Behavioral Care / Mental Health 0 Other: (please specify) Other Settings: 0 Academic 0 Correctional Facility 0 Group Home 0 Emergency Communications 0 Church 0 School 0 Public Safety / Police Department 0 State Government: (please specify Department and Agency) 0 Other: (please specify) 8. In what types of activities are you involved on your job? (Check all that apply) 0 Administration 0 Case Management 0 Clerical 0 Clinical Services 0 Education/Teaching 0 Disease Investigation and control 0 Environmental Health 0 EMS medical direction/coordination 0 Epidemiology 0 First responder 0 Health counseling 0 Health education or promotion 0 Immunizations 0 Insurance/utilization review 0 Patient care 0 Medical priority dispatching 0 Program planning 0 Quality improvement/assurance 0 Research 0 Supervision 0 Telephone triage 0 Finance 0 Security 0 Other: (please specify) 9. Are you willing to travel to other parts of the state to assist with an emergency? 0 Yes 0 No 10. Do you speak any of these foreign languages? 0 Yes 0 No If yes, please list what languages and proficiency in each (limited, intermediate, advanced): a. b. c. 11. Do you know American Sign Language? 0 Yes 0 No 12. Have you had HAZMAT (hazardous materials) training? 0 Yes 0 No If yes, please indicate training level: 0 Awareness 0 Operations 0 Technician 0 Specialist 13. Have you had basic first aid training? 0 Yes 0 No If yes, please indicate year of most recent training: 14. Have you been trained in CPR? 0 Yes 0 No If yes, please indicate year of most recent training: 15. Have you had incident command training? 0 Yes 0 No If yes, please indicate year of most recent training: Please answer the following questions if you are a health care professional. (If not, please proceed to the end of the application for signature.) 16. Do you have training and experience in starting an IV? 0 Yes 0 No If yes, please indicate year of most recent training: 17. Do you have training and experience in giving IV medications? 0 Yes 0 No If yes, please indicate year of most recent training: 18. Do you have training and experience in giving IM medications? 0 Yes 0 No If yes, please indicate year of most recent training: 19. Do you have training and experience in using equipment to manage a person’s airway? 0 Yes 0 No If yes, please indicate year of most recent training: 20. Have you received formal paramedic training or military medical training? 0 Yes 0 No If yes, please indicate year of most recent training: 21. Are you currently or have you previously been credentialed by one of the State of Delaware health professional Boards (example, Board of Nursing)? 0 Yes 0 No If yes, please indicate which Board: 22. If you are credentialed by a state board, what is the status of your primary license, registration, or certification? 0 Active 0 Inactive 0 Other If you currently have a license, please complete the following: (This information will only be used for credentialing purposes) License, Registration, or Certification Number: Expiration Date: month/day/year / / 23. Do you have current or previous experience in a healthcare occupation that is not currently licensed, registered, or certified in the State of Delaware? 0 Yes 0 No If yes, please indicate your primary occupation: 24. Briefly describe the educational, volunteer, or work experience you believe you have that is relevant to volunteering in the event of a public health emergency. 25. How did you hear about the opportunity to become a member of the Delaware Medical Reserve Corps? 0 Brochure/Flyer 0 Internet 0 Professional Organization 0 Presentation 0 TV / Radio 0 Friend/Acquaintance 0 Mailing 0 Article/Publication 0 Other: Acknowledgement I hereby certify that all statements made in this application are true and I agree and understand that any misstatement of material facts may cause forfeiture of my eligibility for enrollment as a Medical Reserve Corps volunteer. I also understand that falsification or omission of information may result in my removal from eligibility as a volunteer. I understand that the information from this application may be shared with federal, state, regional, or local partners in planning for emergency preparedness and with those agencies where I will be placed as a volunteer. I authorize the State of Delaware Public Health Medical Reserve Corps officials to check any information regarding my application and information about criminal background and will agree to submit a separate form indicating authorization to release this information, if necessary. I understand that I have the right to withdraw my application or discontinue my enrollment as a volunteer at any time with written notification to the Delaware Division of Public Health Medical Reserve Corps officials. By signing this application, I agree to the statement above. Signature:_________________________________________________________________ Date:_______________________