Kidney Community Emergency Response Coalition

Thank you for your willingness to serve as a volunteer for the Kidney Community Emergency Response Coalition. This list will serve as a means to quickly identify volunteers. Please complete the following information as the first step to be a volunteer of this emergency preparedness network.

Registering as a volunteer does not necessarily mean you will be called for every disaster that occurs. People will be called as needed.

Please note that volunteers will be responsible for their own transportation to the disaster area.

1. Contact Information

Contact Information Last Name
First Name
Credentials
Home Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
E-mail Address

2. What is your renal nutrition specialty? (Please check all that apply.)

What is your renal nutrition specialty? (Please check all that apply.) CSR

Hemodialysis

Pre-dialysis CKD 1-4

Peritoneal Dialysis

Pediatrics

Transplant

Other (please specify)

3. Experience

Experience Employer
Position/Job Title
Number of Years Experience

4. Experience - Please summarize your experience in renal nutrition.

Experience - Please summarize your experience in renal nutrition.

5. Are you currently certified in the following:

	Yes	No
BLS (Basic Life Support)	*Are you currently certified in the following: BLS (Basic Life Support) Yes	BLS (Basic Life Support) No
ACLS (Advanced Cardiac Life Support)	ACLS (Advanced Cardiac Life Support) Yes	ACLS (Advanced Cardiac Life Support) No

6. What type of job or task are you willing to perform?

What type of job or task are you willing to perform? Clinical

Clerical

Clean-up

Anything Needed

Other (please specify)

7. Are your vaccinations current for the following?

	Yes	No
Tetanus & Diphtheria (TD)	*Are your vaccinations current for the following? Tetanus & Diphtheria (TD) Yes	Tetanus & Diphtheria (TD) No
Hepatitis B	Hepatitis B Yes	Hepatitis B No
Influenza	Influenza Yes	Influenza No
Measles	Measles Yes	Measles No
Annual TB Check	Annual TB Check Yes	Annual TB Check No

8. Please indicate below that you:

Please indicate below that you: If called to help in a disaster area, I agree, prior to deployment, to read any health recommendations that have been issued by the Centers for Disease Control regarding the disaster area. This information can be found on CDC's Web site - http://www.cdc.gov.

Are healthy enough to function under field conditions, such as 12 hour shifts, no showers, housing in tents, no air conditioning, long periods of standing, sleep accomodations on bed roll, military ready to eat meals, and portable toilets.

Acknowledge that due to the extent of the disaster, information on this form may be shared with dialysis providers and agencies in order to meet the needs of the renal community and confidentiality may not be guaranteed.

9. Other Comments

Other Comments

10. The National Disaster Medical System (NDMS) oversees Disaster Medical Assistance Teams (DMAT) that deploy in times of emergency. There is a proposal before the NDMS to have a kidney provider staff who can be federalized and deployed in case of a disaster. If this happens, this information may be forwarded to NDMS. Can we forward your information to NDMS at that time?

The National Disaster Medical System (NDMS) oversees Disaster Medical Assistance Teams (DMAT) that deploy in times of emergency. There is a proposal before the NDMS to have a kidney provider staff who can be federalized and deployed in case of a disaster. If this happens, this information may be forwarded to NDMS. Can we forward your information to NDMS at that time? Yes

11. For Council on Renal Nutrition Use Only

For Council on Renal Nutrition Use Only Date Information Exported
Office Use 1
Office Use 2
Office Use 3
Office Use 4

12. The information provided above is true and correct to the best of my knowledge.

The information provided above is true and correct to the best of my knowledge. Type Signature
Date

Please click "Next >>" once you have completed the above information.

Kidney Community Emergency Response Coalition - Renal Dietitians
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1. Registration Form

Kidney Community Emergency Response Coalition - Renal DietitiansExit this survey >>

1. Registration Form

Kidney Community Emergency Response Coalition - Renal Dietitians
Exit this survey >>