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The Alameda-Contra Costa Medical Association (ACCMA) is helping to coordinate our local response to the COVID-19 emergency. As part of the effort, ACCMA is mobilizing physicians who may now be working a reduced schedule, who are recently retired, part-time, engaged in non-critical research or teaching, or otherwise available. If you are available and willing to volunteer, please complete the following 3-minute survey. Thank you!

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* 1. Name:

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* 2. Cell phone number:

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* 3. Email address:

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* 4. Availability (which we understand may change):

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
AM
PM

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* 5. Medical License Number:

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* 6. Medical License Type:

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* 7. Specialty:

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* 8. Are you currently Board Certified?

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* 9. Active hospital medical staff affiliations, if any:

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* 10. Proficiency in EHR(s):

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* 11. Do you have current malpractice coverage?

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* 12. When were you most recently engaged in clinical medicine? Format of date: MM/DD/YYYY (if exact date unknown, please select the first of the month)

Date

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* 13. Are you willing to serve on a voluntary (unpaid) basis?

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* 14. Language fluency other than English, if any:

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* 15. Is it okay to share your name and information with provider organizations or government agencies?

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* 16. Other comments/ concerns:

Thank you for your interest in volunteering!
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