HAA Volunteer Application Clinical Flight Crew Volunteer Application Question Title * 1. Name: OK Question Title * 2. I reside in U.S.A Canada A Caribbean nation Other (please specify) OK Question Title * 3. Have you volunteered with Haiti Air Ambulance in the past? Yes No OK Question Title * 4. If yes, when was the last time (month / year) you volunteered with Haiti Air Ambulance? OK Question Title * 5. Do you have at least 2 years of rotor wing air medical transport experience? Yes No OK Question Title * 6. Have you ever, volunteered, worked in, or lived in Haiti in the past? Yes No OK Question Title * 7. I am Currently employed full time with a rotor wing air ambulance Have been recently employed full time with a rotor wing air ambulance (within 1 year) I am employed part time with a rotor wing air ambulance OK Question Title * 8. How many years experience total do you have with rotor wing air ambulance transport? OK Question Title * 9. My current (or most recent) rotor wing air ambulance employer is: OK Question Title * 10. Do you have a current Passport this is valid for at least 6 months? Yes No OK Question Title * 11. If you do not have a current Passport, are you in the process of obtaining one? I have a valid Passport I have applied for my Passport I have not started the process of applying for my Passport yet OK Question Title * 12. I can commit to volunteering with Haiti Air Ambulance for a total of ________ days including travel days: 7 days 10 days 14 days 21 days OK Question Title * 13. I am licensed as a (select all that apply): Registered Nurse Nationally Registered Paramedic Paramedic Physician Certified Flight Registered Nurse Flight Paramedic - Certified Respiratory Therapist Primary Care Paramedic Critical Care Paramedic Advanced Care Paramedic Other (please specify) OK Question Title * 14. I am current in the following certifications (select all that apply): ACLS BCLS PALS NRP / STABLE Advanced Trauma Course (TPATC, ATLS, etc) Basic Trauma Course (PHTLS, BTLS) OK Question Title * 15. Are you able to (check all that apply): Purchase short term Medical Repatriation Insurance for your volunteer trip? Provide a COVID-19 negative test completed 72 hours or less prior to travel to Haiti? Obtain recommended vaccinations prior to traveling to Haiti? Provide Haiti Air Ambulance with a current resume or CV? Provide Haiti Air Ambulance with copies of current licenses and certifications? OK Question Title * 16. How did you learn of volunteer opportunities with HAA? Word of mouth Social Media HAA Website Other (please specify) OK Question Title * 17. Briefly explain your interest in volunteering with Haiti Air Ambulance as a clinical flight crew member: OK Question Title * 18. What dates would you be available to come volunteer if selected? OK Question Title * 19. What is your flight-ready weight in pounds? OK DONE
