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COVID-19 Vaccination POD Volunteer Interest
Establishing Susquehanna Conference ERT and VIM response interest and availability
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* Indicates required question
Name
*
Your answer
Cell Phone
*
Your answer
E-mail
*
Your answer
Zip Code
*
Your answer
County
*
Your answer
District
*
Choose
Altoona
Harrisburg
Lewisburg
Scranton/Wilkes-Barre
State College
Williamsport
York
Current Flu Vaccination
*
Yes
No
Required
Current COVID-19 Vaccination - First
*
Yes
No
Required
Current COVID-19 Vaccination - Second
*
Yes
No
Required
Current Certification or License
*
Physician/Doctor
Nurse (LPN/RN)
Medical Student (needs clinical hours)
Paramedic
Paramedic Student (needs clinical hours)
EMT
EMT Student (needs clinical hours)
Medical Assistant
Personal Care Assistant
None
Other:
Do you have Incident Command System (ICS) Training? (ICS 700, 800, 100, 200, 300, 400)
*
Yes
No
Do you have any special skills/abilities/training? (i.e. fire police, data entry, information technology, language skills)
Your answer
Do you have a current background clearance?
*
Yes
No
PA State Police
Department of Public Welfare
FBI
UMCOR ERT Badge
Yes
No
PA State Police
Department of Public Welfare
FBI
UMCOR ERT Badge
Non-medical Jobs/tasks you are interested in assisting with
*
Yes
No
Greeters
Runners
Line Monitors
Screeners
Client Support (functional needs)
Behavioral Health Support
None
Yes
No
Greeters
Runners
Line Monitors
Screeners
Client Support (functional needs)
Behavioral Health Support
None
Medical Jobs/tasks you are interested in assisting with (requires training/certification/license)
*
Yes
No
Dispensers
Vaccination
Emergency Medical Services
Pharmacy Support
None
Yes
No
Dispensers
Vaccination
Emergency Medical Services
Pharmacy Support
None
General Staff Jobs/tasks you are interested in assisting with
*
Yes
No
Orientation (providing instructions)
Directing People
General Support
Directing Traffic
Replenishing Supplies
Distributing Handouts
Coordinating Volunteers
Controlling Waste
Childcare Assistance
Food Service to staff only
Logistics
Set up and/or Tear down
Communications
Cleaning/Janitorial
Registration
Information Technology
Scheduling
None
Yes
No
Orientation (providing instructions)
Directing People
General Support
Directing Traffic
Replenishing Supplies
Distributing Handouts
Coordinating Volunteers
Controlling Waste
Childcare Assistance
Food Service to staff only
Logistics
Set up and/or Tear down
Communications
Cleaning/Janitorial
Registration
Information Technology
Scheduling
None
Do you require any accommodations? (certain jobs/tasks may require long periods of standing, walking, sitting, or lifting)
Your answer
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