Emergency Response Volunteer Nurse Registry
(Please Print)

Name
Address	City/Town/Zip
Phone (Work)	E-mail (W)
Phone (Home)	E-mail (H)
Cell Phone #
Registered Professional Nurse License #
Licensed Practical Nurse License #

 
Vaccination or Illness History

	Date Vaccination/ Illness	Date	Date of Titer	Results Pos/Neg
Measles
Mumps
Rubella
Hepatitis B
Smallpox
Tetanus/Diphtheria (Td)
Chickenpox
PPD (Mantoux)

 

Vaccination Administration Experience: [  ] Yes   [  ] No

Venipuncture Experience: [  ] Yes   [  ] No

CPR Certification: [  ] Yes   [  ] No   Expiration Date: ________________

Language Skills: [  ] Spanish   [  ] French   [  ] Russian   [  ] Other __________________________

Signing (ASL) Skills: [  ] Yes   [  ] No

 

I consent to my medical and identifying demographic information listed above being placed in an electronic and paper Volunteer Nurse Registry at the Tompkins County Health Department for the purposes of potential volunteer work in the event of an emergency. I understand that I can withdraw from the Registry at any time with notification to the Tompkins County Health Department. My medical and identifying demographic information will be kept confidential and will only be shared in an aggregate (group) form.

 
Signature __________________________________________  Date ______________

Adam Hartwig, Bioterrorism Preparedness Coordinator
Tompkins County Health Department
55 Brown Road
Ithaca, NY  14850

If you have any questions:

Call Adam Hartwig at 607-274-6681 or e-mail ahartwig@tompkins-co.org