Healthcare Worker Volunteer Survey

With the number of COVID-19 cases increasing, we want prepare for the possible future in which physicians and other healthcare workers are unintentionally exposed to COVID-19 or become infected, and are subject to a 7-14 day quarantine. To ensure that hospitals and healthcare facilities remains staffed, please consider signing up below to indicate willingness to volunteer should the need arise.

MCMS will share your responses with leadership at both health systems, Monroe County Dept. of Health, and/or other medical offices who may need volunteers.

1.What is your contact information?(Required.)

First Name

Last Name

Email Address

Phone Number

2.Are you currently working?

Yes

3.If you are currently working, please list your current employer

4.If you are not currently working, when did you last work?

5.In what county do you live?(Required.)

6.What is your professional title?(Required.)

7.Are you currently licensed?(Required.)

Yes

Not applicable

8.Are you currently credentialed at any hospitals

9.What is your specialty? (If applicable)

10.Do you have a particular set of skills that you think would be especially helpful?(Required.)

11.How specifically would you like to volunteer to help?(Required.)

12.If possible, indicate what hours/days you would be willing to volunteer?

13.Is there anything else you want to share?