Volunteer Screening Form

Other Organization where you are a volunteer?

Volunteering Preferences - Please check areas where you may have special skills or training.
CPR   Is CPR card current?  Yes   No
First Aid   Is First Aid card current?  Yes   No
Truck Driver   Is CDL license current?  Yes   No
EMT-P
First Responder
EMT-B
Medical License   Is medical license current?  Yes   No 
Title/Type: (MD, RN, NP, etc.)
Emergency communication
Ham Radio Operator
Mass Sheltering
Journalism
Waste Disposal
Recreational Leader
Day/Child Care
Computer skills
Translation skills: Please explain:


Other, please explain:

Please check areas where you may have a position:
Construction
General cleanup
Counseling experience
Food preparation and management
Management and administration skills
Volunteer management
General office skills
Lodging management
Law enforcement
Security experience
Mechanical ability
Structural Engineering

Availability (days and hours):

Comments:

Have you ever been convicted of a felony?   Yes   No
If yes, please explain:

If a public health emergency or other form of emergency has occurred, are there any other organizations (work or volunteer) or responsibilities which will take priority over your efforts to volunteer for Southwest NE Public Health Depart.?  Yes   No
Please explain as much as possible if yes:

EMERGENCY CONTACT

Thank you for your assistance in this community-wide effort!

I am providing my contact information to be part of a confidential database, maintained by the Southwest Nebraska Public Health Department, to be used in the event of a public health emergency. I acknowledge that Southwest Nebraska Public Health Department may need to contact me periodically to maintain the accuracy of this information, or to test their communication plan’s effectiveness. I authorize Southwest Nebraska Public Health Department to contact me utilizing any or all of these methods should the need arise.

For office use only. Please leave this field empty.