Volunteer Contact Tracing Survey

Learn More About Volunteer Contact Tracing

Contact tracing is a process in which officials identify whom an infected person may have exposed and warn them to self-isolate to reduce the spread of the virus. Having effective contact tracing programs in place will be necessary in order to safely reopen our economy. A contact tracing effort will involve a lot of people and local governments are working to increase their capacity to do that work.

If you are interested in learning more about becoming a volunteer to assist with contact tracing, please complete this survey and you will receive additional information as it becomes available.

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* 1. First Name

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* 2. Middle Name

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* 3. Last Name

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* 4. Suffix (Example: Jr., Sr., MD, PhD, RN)

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* 5. Address

Address

Address 2

City/Town

State

ZIP/Postal Code

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* 6. Contact Information

Email Address

Phone Number

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* 7. What is your occupation type?

Medical

Non-Medical

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* 8. Have you ever been arrested or convicted of any criminal offense?
NOTE: Criminal activity is not an automatic rejection of an individual’s approval to volunteer however you will be required to provide additional information regarding the nature of the incident.

Yes

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* 9. How did you hear about this volunteer opportunity?

Colleague

Friend

Social Media Posts

Newsletter

Other

If "Other" please specify

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* 10. Do you authorize the Commonwealth of Pennsylvania to research and copy records including, but not limited to, educational, professional, judicial; armed services; Federal, state and local law enforcement; motor vehicle and driving safety; and any other documents, data, and information that may be necessary and practical in order to conduct an investigation; and to contact past and present employers as well as professional references for information. I also authorize the release of the above mentioned records to the Commonwealth of Pennsylvania. My consent, however, is conditioned upon the understanding that all records, data, and information obtained by the Commonwealth shall be used only for the purposes of determining my fitness for the volunteer position(s) to which I am assigned.

Yes

Volunteer Contact Tracing Survey

Learn More About Volunteer Contact Tracing

Question Title

* 1. First Name

Question Title

* 2. Middle Name

Question Title

* 3. Last Name

Question Title

* 4. Suffix (Example: Jr., Sr., MD, PhD, RN)

Question Title

* 5. Address

Question Title

* 6. Contact Information

Question Title

* 7. What is your occupation type?

Question Title

* 8. Have you ever been arrested or convicted of any criminal offense?NOTE: Criminal activity is not an automatic rejection of an individual’s approval to volunteer however you will be required to provide additional information regarding the nature of the incident.

Question Title

* 9. How did you hear about this volunteer opportunity?

Question Title

* 8. Have you ever been arrested or convicted of any criminal offense?
NOTE: Criminal activity is not an automatic rejection of an individual’s approval to volunteer however you will be required to provide additional information regarding the nature of the incident.