20200427 V-VRC Pre-Deployment Medical/Skills Form
Volunteer Form which introduces us to you, your skills and interests. (Event: COVID-19)
Email address *
Last Name *
First Name *
Cell Phone *
Emergency Contact *
Emergency Contact Relationship *
Emergency Contact Phone *
Have you had a temperature of 100.4 or higher in the past 14 days? *
Have you had a dry cough in the past 14 days? *
Have you had shortness of breath in the past 14 days? *
• Volunteering may require the following duties- i.e. lifting, standing, bending, etc and/or hazards. Are you currently under a health professional’s orders/recommendations that would restrict you from performing any physical or mental activities necessary to perform essential duties/functions for this assignment? *
• Do you require any work-related accommodations for a mental or physical condition(s) that limits your current ability to perform the essential duties/functions of this assignment? *
• Do you have an allergy and/or sensitivity (i.e. irritation to eyes or skin, difficulty breathing) to latex, chemicals or environmental substances that limits your current ability to perform the essential duties/functions of this assignment? *
If you are affiliated with other volunteer organizations, please list them.(i.e. Red Cross, Food Pantries, Scouts)
Please Select the Best Licensed Professions That Applies to you: *
Medical/Professional Skill Specialty
If you are a medical professional, would you be willing to work with potentially virus-exposed citizens? Of course, you will be provided with the appropriate personal protective equipment.
Clear selection
If you are willing to work with potentially virus-exposed citizens, then we would like to test you for the proper fit for an N-95 mask. Are you willing to be fit-tested?
Clear selection
Clerical/Data Entry Skills
Equipment Skills
What other equipment are you trained to use?
Communications/Language Skills
If you speak a second language, what is it?
Services Skills
Building/Structural Skills
Trades Skills Certifications
Transportation Skills
Labor Skills
Other Skills Not Mentioned
Is your ServPA account over 90% completed? *
Did you upload a photo of yourself onto servPA that is appropriate for your identification? We will use it on your badge, so it should be a passport type photo. *
Do you need help in completing your servPA account? *
Have you read through the Delco Handbook? *
Do you agree with the following statement? *
I realize that as a volunteer with the Citizen Corps of Delaware County, I may acquire knowledge or confidential information from files, case records, missions, conversations, etc. I agree that such information is not to be discussed or revealed to anyone not authorized to have the information.
Do you give permission to have your picture taken? *
CCDC uses Social Media to attract new volunteers. We often put photos of our activities on Facebook, Twitter and our website.
Have you completed the NIMS ICS-100 course? *
Have you completed the NIMS ICS-700 course? *
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