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Emergency Response Volunteer Form

Major emergencies can overwhelm the capabities of first responders, particularily during the first 12 to 72 hours. Volunteers can provide an important "surge" capacity during this critical period.  Communities often need volunteers to fill in the gaps in their emergency response plans and to improve their response cababilities overall.  

The Northeast Nebraska Public Health Department (NNPHD) has implemented a volunteer registration system. NNPHD will collect and store contact information on volunteers interested in filling response and recovery roles during and following a major public health emergency. Based on the information collected from each volunteer, public health officials will be able to identify those individuals willing to fill the specific volunteer roles needed in an emergency.  Any personal contact information will remain confidential.  

During an emergency event public health officials will generate a list of volunteers who may be contacted based on the information they provided.  Those contacted will be given information on where to report and the option to accept or decline the opportunity.  Registration does not obligate you to response however, by registering you may be contacted periodically to update your contact information and availability.  

Please complete the form and then click submit at the bottom of the form to send your information to the Northeast Nebraska Public Health Department Emergency Response Coorindator.  

EMERGENCY RESPONSE VOLUNTEER FORM


Personal Information

Today's Date:               

Name (Last, First, MI):            Date of Birth:      

Address:            Day Phone:  

City:     State:     Zip:            Evening Phone:  

County:            Cellular:  

E-mail Address:  

Willing to volunteer in the following county(ies):

Cedar          Dixon          Other  

Wayne        Thurston

Skills:

Please check all that apply.

People Skills   Medical Certification/License   Equipment
Welcoming   Emergency Medical Technician   Forklift
Listening   Certified Nursing Assistant   Bulldozer
Directing traffic flow of people   Licensed Practical Nurse   Backhoe
Explaining a process or form in   Registered Nurse   Generator
  a calm manner   Physician   Tractor 
Communication Skills   Pharmacist   Trailer
CB or Ham Operator   Pharmacy Technician   Other: 
Public Relations   Advanced Reg. Nurse Practitioner   Transportation
Public Speakers   Physician Assistant   Car
Other:    Dentist   Commercial Driver License
Computers   Veterinarian   Station Wagon
Information Technology Specialist   Services   Truck
Repair   Animal Care   Truck 4 Wheel Drive
Software   Animal Rescue   SUV 4 Wheel Drive
Networking   Auto Repair/Towing   Training
Other:   Child Care   Incident Command System ISC 100
Office Support   Elderly/Disabled   Incident Command System ISC 200
Clerical - filing, copying   Preparing or delivering food   Incident Command System ISC 300
Data Entry   Runner (supplies)   Incident Command System ISC 400
Inventory Management   Search and Rescue   Incident Command System ISC 700
Phone Receptionist   Traffic Control   Mass Dispensing
Typing   Other:    Community Emergency Response 
Record Keeping   Labor     Team (CERT)
Quality Control   Clean Up   Crime Watch
Supervision   Loading/Shipping   Other: 
Badging   Sorting/Packing      
Other:   Supervisor      
      Fill Sandbags      
      Other:       

 

Any skills not mentioned above that could be helpful during an emergency response event?  

 

 

 

 

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