HICS Staff Redeployment Survey - Volunteers for Vaccine Distribution 1/13/21 - 1/17/21

Please complete the following availability survey. Thank you.

First Name

Last Name

Department

Immediate Supervisor

Please provide us with the best number to reach you.

Work Telephone

Home Phone

Cell Phone

Memorial Sloan Kettering Email Address

Confirm Memorial Sloan Kettering Email Address

Personal Email Address

Confirm Personal Email Address

Wednesday Availability (1/13/21)

8am – 4pm

Thursday Availability (1/14/21)

8am – 4pm

Friday Availability (1/15/21)

8am – 4pm

Saturday Availability (1/16/21)

8am – 4pm

Tuesday Availability (1/12/21)

8am – 4pm

Please provide detailed answers when appropriate.

If you have worked during an emergency previously, what did you do?

What medical, nursing, allied health training, medical experience or technical skills do you have?

Are you fluent in any other languages?

Yes

Please indicate language below