NMA 2010 Haiti Survey

1. 2010 NMA Response to the Haiti Earthquake

The National Medical Association is seeking information on members' and non-members' interest serving in various relief efforts in Haiti. Please help us respond to the earthquake in Haiti by completing the survey below.

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1. What is your specialty?

What is your specialty?

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2. Are you aware of the extent of the need for health care in Haiti?

Are you aware of the extent of the need for health care in Haiti? Yes

3. Would you be willing to work in any of the following areas?

Would you be willing to work in any of the following areas? Primary Care

Amputation and limb support

Mental Health

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4. As a Physician, are you interested in donating your services in a hospital-based setting in Haiti? If yes, then please continue to question #5. If no, then please skip to question # 12.

As a Physician, are you interested in donating your services in a hospital-based setting in Haiti? If yes, then please continue to question #5. If no, then please skip to question # 12. Yes

5. What would be your preferred length of service in a hospital-based setting in Haiti?

What would be your preferred length of service in a hospital-based setting in Haiti? One Week

Two Weeks

Three Weeks

Four or More Weeks

6. How much notification time would you need to be ready to deploy?

How much notification time would you need to be ready to deploy? Three Days

One Week

One Month

Two Months

Three Months

7. When is your preferred start date?

	MM		DD		YYYY
First Choice	When is your preferred start date? First Choice Month	/	Day	/	Year
Second Choice	Second Choice Month	/	Day	/	Year
Third Choice	Third Choice Month	/	Day	/	Year

8. Would you volunteer realizing that the trip will require that you cover your travel and meal expenses during the time away?

Would you volunteer realizing that the trip will require that you cover your travel and meal expenses during the time away? Yes

9. Have you ever been deployed to clinically support a public health emergency or disaster?

Have you ever been deployed to clinically support a public health emergency or disaster? Yes

If yes, then where and when?

10. Which of the following disaster life support courses have you taken?

Which of the following disaster life support courses have you taken? Basic Life Support (BLS)

Advanced Cardiovascular Life Support (ACLS)

Other (please specify)

11. Are you affiliated with any organizations that provide emergency relief in Haiti?

Are you affiliated with any organizations that provide emergency relief in Haiti? Yes

If yes (please specify)

12. What languages do you speak?

What languages do you speak? English

French

Spanish

Creole

Other (please specify)

13. Do you have any experience in providing care in Haiti?

Do you have any experience in providing care in Haiti? Yes

If yes, when?

14. Are you of Haitian decent?

Are you of Haitian decent? Yes

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15. Are you able to donate or raise any of the following items, domestically, in order to aid the NMA relief efforts in Haiti?

Are you able to donate or raise any of the following items, domestically, in order to aid the NMA relief efforts in Haiti? Medical Goods

Money

Other Supplies

None

Medical Goods/Other (please specify)

16. Are you a Medical Administrator?

Are you a Medical Administrator? Yes

If yes. Please tell us your area of expertise.

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17. Do you know any other Physicians that would be interested in volunteering?

Do you know any other Physicians that would be interested in volunteering? Yes

If yes, please indicate their name and e-mail address.

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18. Would you like a someone from the NMA to contact you for more information about volunteer opportunities?

Would you like a someone from the NMA to contact you for more information about volunteer opportunities? Yes

If yes, please write your name and the best time and way to reach you

NMA 2010 Haiti