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UC COVID-19 Volunteer Surge Availability 2
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1.
Please enter your contact information
(Required.)
Name
Email Address
Phone Number
*
2.
What is your skillset/professional designation?
(Required.)
Doctor
Physicians Assistant
RN
APRN
LPN
CNA
Medical Technician
Mental Health/Social Work Support
General Support Staff
Other (please specify)
*
3.
Do you possess a current NYS Professional License?
(Required.)
Yes
No
*
4.
If you do possess a current NYS Professional License, please enter the #
(Required.)
*
5.
Can you work at a
local
,
to be determined) UC surge facility (hospital or other)?
(Required.)
Yes
No
*
6.
How many days per week (1-7) would you be available to work/volunteer?
(Required.)
1
2
3
4
5
6
7
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7.
Can you work weekdays, weekends, or both?
(Required.)
Weekdays (M-F)
Weekends (Sat-Sun)
Both
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8.
Are there any days of the week that you CANNOT work (check as many as apply)?
(Required.)
M
T
W
TH
F
SAT
SUN
*
9.
Can you work day, evening and overnight shifts (check as many as apply)?
(Required.)
Day only
Evening only
Overnight only
*
10.
Shift durations are either 4-hour or 8-hour. Please select your preference
(Required.)
4-hour shift
8-hour shift
I can work either 4 or 8
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