Application Form for Interest & Availability for Medical Surge Support of Ukraine Refugees
The WHO Regional Office for Europe is looking to identify international medical surge availability to stand by for potential requests of support from Ukraine and neighboring countries.

We are working with Global Response Management to gauge interest and availability in sending volunteers as part of a GRM response for persons displaced from Ukraine.

At this time this is a volunteer response and while costs and travel will be deferred through Penn and GRM, interested individuals will need to arrange time off work with their individual unit leadership.

We are currently seeking healthcare providers, preferably with previous experience in global health, care of refugee populations, military experience or international or disaster response as well providers with ties to the Ukraine or with critical language skills.

At this time information is still forthcoming but we anticipate a rapid need for emergency providers (physicians and nurses) and possible support from surgical teams, this followed by medical professionals of all types.

We are asking for a minimum commitment of 7 consecutive days though 14 days is preferred. Extended deployment up to 90 days is available. Travel may begin as early as March 20th. The situation is fluid and dates may shift so please enter your widest availability to participate.

GRM will require background checks for all who are selected for deployment. UPHS clinicians who treat pediatric age patients are already required to complete such a background check and that may be used here for deployment.  All others must complete this check prior to selection by GRM. Background checks can be obtained with minimal cost at this site: https://app.sterlingvolunteers.com/en/Candidates/Account/Register 

Registration of interest does not guarantee deployment with GRM but will help us a build a bench of interested and available personnel.

Penn Medicine Ukraine Relief Portal: https://www.med.upenn.edu/globalhealth/penn-medicine-ukraine-relief-portal/ 

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Do you have a valid passport (Expiration no longer than 6 months from date of travel) *
Have you received two or more doses of the COVD-19 vaccine? *
Please provide your first name as it appears on your passport *
Please provide your middle name if it is listed on your passport
Please provide your last name as it appears on your passport *
Please provide your preferred email *
Please provide your phone number (mobile numbers preferred) *
What is your professional role at Penn Medicine? *
Please provide your primary practice site *
What department are you a member of? *
What are your areas of clinical expertise? *
Do you have a valid and current license and/or certification to practice professionally in this (these) domains?
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Do you have any of the following certifications:
Briefly describe any potentially relevant experience (e.g., prior work with refugees, military training, other international medical experience) *
Are you in good health and do you consent to provide relevant PHI to that effect? *
Have you completed a background check as part of your credentials process for UPHS? *
Level of proficiency with the Russian language *
Level of proficiency with the Ukrainian language *
Level of proficiency with the Polish language *
Number of consecutive days available on-site *
Would you be interested in deploying more than once (not consecutively) within the 90-day period? *
Please select the weeks you are available to travel. At this time travel days will likely be Sunday - Sunday however this may change. Please select all of the weeks you are available to start travel, this does not mean you would be required to volunteer for all of the weeks selected *
Required
Do you have any other skills or information related to this response you think are important for us to know?
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