HCW HOSTED Registration of Interest

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Welcome to HCW HOSTED!

Thank you for your service on the front lines of the COVID-19 pandemic. Now it’s our turn to serve you.

Please fill out the following survey so that we can match you with available housing. After you submit this survey, a HOSTED coordinator will call you in 1-2 business days.

Please note: we currently only have housing available in Tucson, AZ.

Part 1: Contact info

First Name *

Last Name *

Mobile Phone number *

E-mail

Preferred contact method *

Phone

Text

Required

What is the best time of day to reach to reach you? *

Would you like to be contacted in Spanish? *

Yes

Part 2: Work Information

What is the name of your primary employer *

Name/Location of your primary work site

What is your job title *

Nurse

Physician

Resident Physician

Nurse Practitioner

Clinical Pharmacist

Medical Technician

Respiratory Therapist

Unit Coordinator or Administrative Support. (e.g. patient registration)

Environmental Services

Student working clinically

Social Worker/ Case Management

Pre-hospital/ EMS Provider

Administrator

Other:

Part 3: Current Health Status Related to COVID-19

In the past 14 days, have you experienced any symptoms of COVID-19? *

Yes

Do you have any of the following conditions? (check all that apply) *

Chronic lung disease (asthma/emphysema/COPD)

Diabetes Mellitus

Cardiovascular Disease

High blood pressure/ Hypertension

Chronic Kidney Disease

Chronic Liver Disease

Immunocompromised Condition

Neurologic/neurodevelopmental/intellectual disability

Medication known to affect/compromise immune system

Currently Pregnant

Required

Part 4: You and Your Household

In what year were you born?

Zip code of permanent residence

What town are you currently residing in? *

In your permanent residence, do you live with children?

Yes

Clear selection

In your permanent residence, do you live with someone with any of the following conditions? (check all that apply)

Chronic lung disease (asthma/emphysema/COPD)

Diabetes Mellitus

Cardiovascular Disease

High blood pressure/Hypertension

Chronic Kidney Disease

Chronic Liver Disease

Immunocompromised Condition

Neurologic/neurodevelopmental/intellectual disability

Medication known to affect/compromise immune system

Currently Pregnant

Clear selection

Name and phone number of an emergency contact we may reach out to (in an emergency)

Name of emergency contact *

What is your relationship to the emergency contact? *

Phone of emergency contact: *

Questions and comments

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