Community Vaccine Clinic Volunteer Form Question Title * 1. Today's Date Date / Time Date OK Question Title * 2. What is your contact information> Name (Full name) Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Primary Phone Number OK Question Title * 3. What is your Date of Birth? Date / Time Date OK Question Title * 4. Who is your Emergency Contact? Name Relationship Phone Number Alt. Phone Number OK Question Title * 5. Do you hold a current New Hampshire Driver's License Yes No What is your NH Driver's License number? OK Question Title * 6. Check your profession/occupation. (Check all that apply) Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) Physician's Assistant (PA) Nurse Practitioner Advanced Practice Registered Nurse (APRN) Registered Nurse Licensed Practical Nurse (LPN) Nursing Students Certified Medical Assistant (CMA) Registered Medical Assistant EMT - Advanced EMT - Paramedic Pharmacist Pharmacy Interns Pharmacy Technician Doctor of Dental Surgery (DDS) Dental Hygienist Mental Health Professional Veterinarian Respiratory Therapist EMS Professional Other Public Health/Medical Other Public Health/Non-Medical Non- Public Health/Non-Medical Retired Please specifiy OK Question Title * 7. What role would you be interested in/able to do? (Check all that apply) Traffic Control (Administrative role that is able to stand on their feet and direct traffic in and out of the clinic) Vaccinator (Clinical role that has been trained to administer vaccinations) Runner/Logistics (Administrative role that is able to stand on their feet and receive supplies for clinics) Educator (Administrative or clinical role; feel comfortable educating patients who may have questions) Observer (Clinical role; will observe patients for adverse reactions after they receive vaccine, be able to treat patient if adverse reaction) Registration (Administrative role; Be well versed with computers) Reconstitutor/Drawer (Clinical role that has experience drawing up medications) OK Question Title * 8. Are you currently an employee of Cheshire Medical Center? Yes No OK Question Title * 9. Are you currently an employee of Monadnock Community Hospital? Yes No OK Question Title * 10. Are you part of any other emergency/disaster response/alert system? Yes No OK Question Title * 11. If yes, which one? American Red Cross Citizen Crops CERT Other (please specify) OK Question Title * 12. Do you know American Sign Language? Yes No OK Question Title * 13. Do you speak a foreign language? Yes No OK Question Title * 14. If yes, please list below. OK Question Title * 15. Please rate your ability for the languages you know. Beginner Average Fluent Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 16. Do you have teaching experience?(ie. teaching/education/communicating detailed information to others etc.) Yes No OK Question Title * 17. Do you have any leadership experience and continued interest? Yes No OK Question Title * 18. Do you have interest in receiving the COVID-19 vaccine? Yes No I already have an appointment scheduled. I already have had one vaccination. I already have had two vaccinations. OK Question Title * 19. I would be willing to.......(Check all that apply) Volunteer internally with Monadnock Community Hospital Volunteer internally with Cheshire Medical Center Support the hospitals as well as the Greater Monadnock Public Health Network in community vaccination clinics OK Question Title * 20. Check the appropriate boxes if they apply to you: At the time of application submission, I am 65 years of age or older. I have one or more of the following underlying medical conditions: Chronic lung disease, moderate to severe asthma, a serious heart condititon, immune deficiencies, diabetes, chronic kidney disease, liver disease, or are currently on dialysis. OK Question Title * 21. What is your current availability? Check all that apply (This is not a commitment, and will help us with better understanding capacity). Days (M-F) Days (Sat-Sun) Evenings (M-F) Evenings (Sat-Sun) Nights (M-F) Nights (Sat-Sun) OK Question Title * 22. Is there anything else you would like us to know? OK DONE