Retired Clinician COVID-19 Survey

Please complete the information below.

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* 1. Name (Last Name, First Name)

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* 2. What Phone Number May We Use To Contact You If Needed?

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* 3. What Is Your Email Address?

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* 4. What Were Your Professional Credentials?

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* 5. Do you currently have an active license in the professional credentials listed that allows you to provide care for non-family members?

Yes

No

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* 6. If You Answered No to Question #5, what month and year did your license go to an "inactive" or "retired" status?

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* 7. What Was Your Speciality?

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* 8. What Was Your Last Clinical Position with WellSpan?

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* 9. What Year Did You Retire?

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* 10. Did You Use Epic (electronic health record) Prior to Retiring?

Yes

No

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* 11. What Is Your Age?

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* 12. Do You Have Any Chronic Medical Conditions That Would Put You At Risk from COVID-19 Complications?

Yes

No

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* 13. Are You Willing to Have Direct Patient Contact?

Yes

No

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* 14. How Many Hours a Week Would You Be Willing to Volunteer?

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* 15. Which County Would You Prefer to Serve?

Adams County

Lancaster County

Lebanon County

York County

Franklin County

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* 16. Thank You For Your Participation In This Survey! Based on the Information Provided, We Will Contact You To Discuss Ways to Participate! Thank You!!!!