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* 1. Today's Date

Date

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* 2. What is your contact information>

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* 3. What is your Date of Birth?

Date

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* 4. Who is your Emergency Contact?

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* 5. Do you hold a current New Hampshire Driver's License

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* 6. Check your profession/occupation.  (Check all that apply)

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* 7. What role would you be interested in/able to do? (Check all that apply)

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* 8. Are you currently an employee of Cheshire Medical Center?

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* 9. Are you currently an employee of Monadnock Community Hospital?

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* 10. Are you part of any other emergency/disaster response/alert system?

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* 11. If yes, which one?

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* 12. Do you know American Sign Language?

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* 13. Do you speak a foreign language?

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* 14. If yes, please list below.

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* 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.

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* 16. Do you have teaching experience?
(ie. teaching/education/communicating detailed information to others etc.)

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* 17. Do you have any leadership experience and continued interest?

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* 18. Do you have interest in receiving the COVID-19 vaccine?

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* 19. I would be willing to.......(Check all that apply)

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* 20. Check the appropriate boxes if they apply to you:

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* 21. What is your current availability?  Check all that apply (This is not a commitment, and will help us with better understanding capacity). 

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* 22. Is there anything else you would like us to know?

0 of 22 answered
 

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