NJHC - New Jersey Health Care Professional Registry

 

State of New Jersey Medical Reserve Corps
New Jersey Department of Health and Senior Services

Health Care Professional Volunteer Application

NEWARK DEPT OF HEALTH MEDICAL RESERVE CORPS

Date of Application (mm/dd/yyyy)

Personal Information
Last Name

 First Name
 Middle Name
 Nickname
Date of Birth (mm/dd/yyyy)
Street Address

 City
 County
 State:
 Zip
Mailing Address (if different)

 City
 State
 Zip
Note: Please enter at least one Phone No.
Home Phone Number:
- - 		Home Fax Number:
- -
Cell Phone Number
- - 		Pager Number
- -
Provide the e-mail where you want to receive messages
Do you possess a valid driver's license?  Yes       No
Driver's License Number

 Expiration Date
 Class
   		State:

Employment Information
Place of Employment
Work Address

 City
    		 State
 Zip
Work Phone Number
- - Extn 		 

Emergency Contact - Will be notified in case of an emergency.
Last Name

 First Name
 Relationship
Street Address

 City
    		 State
 Zip
Note: Please enter at least one Phone No.
Home Phone Number
- - 		Work Phone Number
- - Extn
Cell Phone Number
- - 		Pager Number
- -

Additional Information
Language: Fluent? Speak? Read? Write?
 
Question
Yes    No
Comment
Are you willing to travel and volunteer outside of your county?     
Are you willing to participate in a Federally coordinated emergency response?     
Willing to provide translation service?     
Do you have ability to communicate using sign language?     
Have you been immunized against Smallpox?     
Year of most recent smallpox vaccination
Do you have any special needs or restrictions? If so, please explain.     
Are you committed to any other organization or institution, by virtue of employment or volunteerism, in the event of a public health emergency? If yes, explain.     
Do you have particular expertise and agree to be available for consultation or response throughout the state?     
Has your professional license or certification ever been suspended or revoked in New Jersey or any other state.     

Professional Licensure, Certification, Specialties, Experience

Name on License/ Certification

License/Certification Number

State on License/Certification
 License Type
 Status

Speciality within the above professional licensure/certification that you possess:
Sub speciality within the above professional licensure/certification that you possess:

Experience: Do you have any of the following skills?
  DC (Doctor of Chiropractic)   Surgical Technician
  DCM (Doctor of Chiropractic Medicine)  
  DDS, DMD (Dentists)   PharmD (Doctor of Pharmacy)
  DO (Doctor of Osteopathy)   Pharmacy Assistant
  DPM (Podiatrist)   Pharmacy Technician
  DVM (Veterinarian)   Registered/Licensed Pharmacist
  MD (Medical Doctor)  
  OD (Optometrist)   Certified/Licensed Social Worker (CSW, LCSW, other)
  PA (Physicians Assistant)   Marriage and Family Therapist
    Medical Record and Health Information Technicians
  CRNA (Nurse Anesthetist)   Mental Health Counselor
  LPN (Licensed Practical Nurse)   Mental Health Social Worker
  NP (Nurse Practitioner)   Mental Health Therapist
  Nurse Midwife   Social Worker (BSW, MSW)
  Nursing Assistant/Patient Care Associate   Substance Abuse Social Worker
  RN (Registered Nurse)  
    Environmental Health Specialist
  Cardiovascular Technologists and Technicians   Epidemiologist
  Dental Technician   Health Educator
  Diagnostic Medical Sonographers   Health Officer
  EMT (Emergency Medical Technician)   Health Planner
  Funeral Director/Mortician   Industrial Hygienist
  Informational Technologist (IT)   Microbiologist
  Laboratory Technician   Pastoral Care Professional
  Medical and Clinical laboratory Technologists   Psychologist
  PT/OT (Physical or Occupational Therapist)   Public Information Officer
  Paramedic   Student of the Health Professions, please specify
  Radiology Technician   Translator/Linguist
  Respiratory Therapist  

Training/Continuing Education
Have you completed any training or continuing education programs in the following areas? If so, please check.
  Advanced Cardiac Life Support (ACLS)   Hazardous Materials Training (HAZMAT) Biological
  Advanced Trauma Life Support (ATLS)   Hospital Preparedness
  Basic Cardiac Life Support (BLS)   Incident Command Training (ICS)
  Basic Disaster Life Support (BDLS)   Isolation and Quarantine
  Bloodborne Pathogens   Mental Health Training for Disasters
  CBRNE Training   Pediatric Advanced Life Support (PALS)
  Citizen Emergency Response Team (CERT) Training   Triage
  CPR/AED   Vaccination administration smallpox
  Exercise design and evaluation   Vaccination administration
  First Aid   Venipuncture
  Fit Testing for Particulate Respirators   Weapons of Mass Destruction (WMD) Training


Expectations of NJ Medical Reserve Corps Professional Health Volunteers
As a volunteer with the New Jersey Medical Reserve Corps, I will be called upon to assist in the event of a public health emergency. I agree to attend an educational program to explain my role in disaster preparedness; I will be assigned duties based on my level of training and experience. I understand that submitting this application does not guarantee acceptence into the NJ Medical Reserve Corps. The information contained in this application is, to the best of my knowledge, truthful. I agree to serve my fellow citizens to the best of my professional ability.


I Agree to the above statement
Failure to agree to the above statement invalidates application.


     

Required Field
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