COVID VACCINATION VOLUNTEERS

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* 1. Please enter your name

First Name

Middle Name or Initial

Last Name

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* 2. What is the best phone number to reach you at?

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* 3. What is your email address (enter none if unavailable)?

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* 4. Are you a licensed health care provider (i.e. doctor, nurse practitioner, registered nurse, licensed practical nurse, etc.)?

Yes

No

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* 5. If you are a licensed health care provider, what is your profession?

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* 6. If you are a licensed health care provider, what is your license number (write N/A if not applicable) ?

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* 7. If you are a licensed health care provider, is your registration current?

Yes

No

Not Applicable

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* 8. If you are a licensed health care provider, have you been N-95 fit tested?

Yes

No

Not Applicable

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* 9. If you are NOT a licensed health care provider, what is or was (if retired) your occupation?

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* 10. Do you have experience administering vaccines?

Yes

No

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* 11. Are you trained in Cardiopulmonary Resuscitation (CPR)?

Yes

No

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* 12. If you have been trained in CPR, is your CPR training current?

Yes

No

Not applicable

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* 13. Do you have professional liability insurance?

Yes

No

Not applicable

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* 14. Do you know how to use a computer or tablet?

Yes

No