Haiti Volunteer Registry
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The information collected in this database will be used specifically for disaster response to Haiti. Thank you for your willingness to assist.
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1
. First Name:
First Name:
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2
. Last Name:
Last Name:
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3
. E-mail Address:
E-mail Address:
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4
. AAO ID Number:
AAO ID Number:
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5
. Office Phone:
Office Phone:
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6
. Mobile Phone:
Mobile Phone:
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7
. State:
State:
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8
. Country:
Country:
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9
. Profession:
Profession:
Ophthalmologist
Physician, non-ophthalmologist
Registered Nurse
Ophthalmic technician/allied health professional
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10
. I am willing to serve for:
I am willing to serve for:
1 week
2 weeks
3 weeks
1 month
More than a month
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11
. I have specialized training and/or experience in: (check all that apply)
I have specialized training and/or experience in: (check all that apply)
Administration/Management
Cataract
Comprehensive Ophthalmology
External/Cornea
Glaucoma
Neuro-ophthalmology
Pediatric Ophthalmology
Plastic & Reconstructive Surgery
Primary Care
Public Health
Rehabilitative Medicine/Low Vision
Retina
Statistics/Epidemiology
Other (please specify):
12
. In addition to English, I can speak the following languages: (check all that apply)
In addition to English, I can speak the following languages: (check all that apply)
Creole
French
Spanish
Other (please specify):
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13
. I prefer to provide the following service(s): (check all that apply)
I prefer to provide the following service(s): (check all that apply)
Teaching services
Clinical Services - Medical Eye Care
Clinical Services - Surgical Eye Care
Other (please specify):
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14
. I have experience working in a disaster area:
I have experience working in a disaster area:
Yes
No
15
. Comments:
Comments:
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