SE District Health Department

SE District Health Department

Disaster Response Volunteer Intake Form

Today's Date*

First Name*

Middle Name*

Last Name*

Address*

City/State/Zip*

County*

Mailing Address

If different from above.

Home Phone*

( ) -

Mobile Phone / Pager

( ) -

Work Phone

( ) -

FAX

( ) -

Email*

Occupation

Place of employment

Date of Birth*

Gender*

Female
Male

Ethnicity

African American
White
Hispanic
American Indian / Alaskan Native
Asian / Pacific Islander
Other (Please Describe Below)

Ethnicity Description

Counties willing to serve*

All
Butler
Fillmore
Gage
Jefferson
Johnson
Lancaster
Nemaha
Otoe
Pawnee
Polk
Richardson
Saline
Saunders
Seward
Thayer
York
Other

Affiliation with any other volunteer agencies, first responder agencies or hospitals

Local American Red Cross Disaster Mental Health (DMHS)
Local American Red Cross
National American Red Cross Disaster Services Human Resources Systems (DSHR)
Nebraska Critical Incicdent Stress Management Team
Local Hospital, Clinic or Other Affiliation (Please Describe Below)

Local Hospital, Clinic or Other Affiliation Description

Volunteer Skills

Please check all that apply

Bus/Truck Driver (with current CDL)
Bus/Truck Driver (CDL is not current)
CPR (with current CPR Card)
CPR (CPR Card is not current)
Emergency Communications
First Aid (with current First Aid Card)
First Aid (First Aid Card is not current)
Administration
Office Skills
Animal Care
Basic Clean-Up
CB Radio Operator
Child Care
Programmer
Data Entry
Computer Network Administration
Construction
Food Preparation
Heavy Equipment Operator
Law Enforcemen / Security
Mechanical Ability
Waste Disposal
Counseling
Interpretation (Please Describe Skills Below)
Translation (Please Describe Skills Below)
Other (Please Describe Skills Below)

Interpretation/Translation/Other Skills Description

Licenses or Certifications

Please check all that apply

Certified Master Social Worker
Provisionally Certified Master Social Worker
Certified Professional Counselor
Certified Social Worker
Licensed Alcohol and Drug Counselor
Provisionally Licensed Alcohol and Drug Counselor
Licensed Mental Health Practitioner
Provisionally Licensed Mental Health Practitioner
Marriage and Family Therapist
Psychiatrist
Psychologist
Provisional Psychologist
Psychological Assistant
Physician
Physician Assistant
Advanced Practice Registered Nurse
Certified Nursing Assistant
Liscensed Practical Nurse
Certified Registered Nurse Anesthetist
Registered Nurse
Nurse Practitioner
Nurse Aid
X-Ray Technician
Medication Aide
Epidemiologist
Microbiologist
Mortuary Service
Nutritionist
Phlebotomist
Respitory Therapist
Lab Technician
Pharmacist
Dentist
Clergy
Emergency Medical Technician (EMT)
EMT - Intermediate
EMT - Paramedic
First Responder
Commercial Driver's License
Veterinarian
Veterinarian Technician
Licensed Child Care Provider
Other (Please Describe Below)

Other License or Certification Description

Has your professional liscense ever been suspended, revoked or disciplined?*

yes
no

If yes, please explain.

Are you board certified?

yes
no

Do you have prescripive authority?

yes
no

Emergency Volunteer Center (EVC) Roles

Each county may set up an EVC to process additional volunteers. Please mark ANY roles in which you are willing to work at an EVC.

Data Entry
Greeter
Identification Staff
Interviewer
Phone Bank Staff
Safety Orientation
Runner

TRAINING

Please list an approximate date for all that apply

Community Emergency Response Team (CERT)

FEMA Crisis Counseling Grant

Emergency Medical Technician (EMT)

Critical Incident Stress Management Basic (CISM)

Critical Incident Stress Management Advanced

American Red Cross Disaster Mental Health

Bloodborne Pathogens

National Incident Management Systems (NIMS)

Epidemiology

Bioterrorism

Psychological First Aid

American Red Cross

First Responder

Clergy

Other (Please Describe Below)

Other Training Description

Specializations

Agriculture Work
Children
Developmentally Disabled
Homeless
Minority Populations
Non-English Speakers
Older Adults
Physically Disabled
Prisoners
Substance Abuse
Serious Mental Illness
Other (Please Describe Below)

Other Specialization Description

Have you ever been convicted of a felony?*

yes
no

If yes, please explain including dates

Emergency Contact: Name*

Emergency Contact: Relationship*

Emergency Contact Home Phone*

( ) -

Emergency Contact Mobile Phone*

( ) -

Emegergency Contact Address*

Emergency Contact City/State/Zip*

*

Do you have children or family members who would need care in the event that you are activated?

yes
no

If yes, can you make arrangements for a back-up in the event you are activated?

yes
no

How did you learn about this volunteer opportunity?

Is there any other information we need to know?

Electronic Signature / Release of Information

To the best of my knowledge the information I have provided is accurate. I am providing my contact information to be part of a confidential database, maintained by public health departments, Volunteer Partners, and Region V Systems, to be used in the event of a disaster and to promote community preparedness. I acknowledge that public health departments, Volunteer Partners, Region V Systems, and/or Emergency Management may need to contact me periodically to maintain the accuracy of this information, inform me of training opportunities, or to test their communication plan's effectiveness. I authorize all of the above-mentioned entities to contact me, utilizing any or all of these methods should the need arise, and I agree to release all of the above-mentioned entities from Iiability arising from any volunteer service I may perform. I also authorize any of the entities mentioned above to conduct a background check on me with the information I have provided above.

By completing the name, date and confirmation code below you are signing in agreement to the above statement.

First and Last Name*

Signature Date*

Confirmation Code:

Enter the code shown in the box before clicking on submit.

Note: Fields marked by an asterisk (*) are required.