Retired Clinician COVID-19 Survey Please complete the information below. Question Title * 1. Name (Last Name, First Name) OK Question Title * 2. What Phone Number May We Use To Contact You If Needed? OK Question Title * 3. What Is Your Email Address? OK Question Title * 4. What Were Your Professional Credentials? OK Question Title * 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 OK Question Title * 6. If You Answered No to Question #5, what month and year did your license go to an "inactive" or "retired" status? OK Question Title * 7. What Was Your Speciality? OK Question Title * 8. What Was Your Last Clinical Position with WellSpan? OK Question Title * 9. What Year Did You Retire? OK Question Title * 10. Did You Use Epic (electronic health record) Prior to Retiring? Yes No OK Question Title * 11. What Is Your Age? OK Question Title * 12. Do You Have Any Chronic Medical Conditions That Would Put You At Risk from COVID-19 Complications? Yes No OK Question Title * 13. Are You Willing to Have Direct Patient Contact? Yes No OK Question Title * 14. How Many Hours a Week Would You Be Willing to Volunteer? Up to 4 Hours Between 4 to 8 Hours Up to 12 Hours OK Question Title * 15. Which County Would You Prefer to Serve? Adams County Lancaster County Lebanon County York County Franklin County OK Question Title * 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!!!! OK DONE
