UC COVID-19 Volunteer Surge Availability 2

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* 1. Please enter your contact information

Name

Email Address

Phone Number

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* 2. What is your skillset/professional designation?

Doctor

Physicians Assistant

RN

APRN

LPN

CNA

Medical Technician

Mental Health/Social Work Support

General Support Staff

Other (please specify)

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* 3. Do you possess a current NYS Professional License?

Yes

No

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* 4. If you do possess a current NYS Professional License, please enter the #

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* 5. Can you work at a local, to be determined) UC surge facility (hospital or other)?

Yes

No

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* 6. How many days per week (1-7) would you be available to work/volunteer?

1

2

3

4

5

6

7

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* 7. Can you work weekdays, weekends, or both?

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)?

M

T

W

TH

F

SAT

SUN

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* 9. Can you work day, evening and overnight shifts (check as many as apply)?

Day only

Evening only

Overnight only

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* 10. Shift durations are either 4-hour or 8-hour. Please select your preference

4-hour shift

8-hour shift

I can work either 4 or 8