QVHD MEDICAL RESERVE CORPS VOLUNTEER SIGN UP

Medical Reserve Corps Application

As COVID-19 continues to impact our state, the Department of Public Health is preparing for staffing shortages in both the public health & healthcare fields. If you are able to assist with local response please answer the questions below and QVHD will contact you with additional information.

Learn more about the MRC: www.qvhd.org/qvhd-mrc

Learn more about COVID-19: www.qvhd.org/coronavirus-response | CT.gov/coronavirus

QUESTIONS: KS@QVHD.ORG

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* 1. Please enter your contact information

Name *

Company

Address *

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address *

Phone Number *

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* 2. I am available and willing to assist with any non-medical functions

Yes

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* 3. I have medical credentials and am willing to support local hospital functions if they request volunteers.

Yes

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* 4. If yes, please indicate your credential

LPN

APRN

Other (please specify)

QVHD MEDICAL RESERVE CORPS VOLUNTEER SIGN UP

Medical Reserve Corps Application

Question Title

* 1. Please enter your contact information

Question Title

* 2. I am available and willing to assist with any non-medical functions

Question Title

* 3. I have medical credentials and am willing to support local hospital functions if they request volunteers.

Question Title

* 4. If yes, please indicate your credential

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* 5. Please share your state of CT license number so we can verify your credentials

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* 6. Do you speak any other language other than English? If so, what language?

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* 7. QUESTIONS/COMMENTS