RNRN Disaster Relief Volunteer Form Be there for patient care... Thank you for signing up with the RN Response Network (RNRN), a project of the California Nurses Foundation (CNF). RNRN is a national network of direct care RNs - powered by National Nurses United (NNU) - that coordinates sending volunteer RNs to disaster stricken areas where and when they are needed most. Registering as an RNRN volunteer does not automatically mean you will be called for a disaster. RNs will be asked to volunteer based on need and availability. PLEASE JOIN US TODAY! Download & share the RNRN brochure Please complete this form if you are interested in volunteering for RNRN relief deployments. If you have already signed up as a volunteer and would like to update the information you have already submitted you can log in here to access your information. Thank you for volunteering with RNRN/NNU.

First name

Last Name

Address

City

State/Province (Please Select) Please Select AK AL AZ AR CA CO CT DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY International

Zip/Postal Code

Home Phone ( ) -

Cell Phone ( ) -

Primary Email



(for updating your info later) Password:(for updating your info later)

Are you a Registered Nurse? yes no

Are you a Nurse Practitioner? yes no

RN License Number

RN License Current? yes no

RN License Restrictions? yes no

Hospital/Facility or Affiliation & Location (example: Mountainview Hospital, UCLA Medical Center, or Not Working)

What unit do you currently work in? ER ICU MEDSURG PEDS PSYCH ORTHO NICU OR PACU/RECOVERY ROOM WOUND CARE ANESTHETIST/CRNA PUBLIC/COMMUNITY HEALTH TELEMETRY HOME HEALTH/HOSPICE REHAB POST PARTUM L&D OB NURSERY OTHER (Enter below)

Other Unit or Expertise? (For example Wound Care. HIV AIDS Clinic, or other units you have worked in extensively but are not your current unit.)

Please select all of the units you would feel comfortable working in: ER ICU MEDSURG PEDS PSYCH ORTHO NICU OR PACU/RECOVERY ROOM WOUND CARE ANESTHETIST/CRNA PUBLIC/COMMUNITY HEALTH TELEMETRY HOME HEALTH/HOSPICE REHAB POST PARTUM L&D OB NURSERY OTHER (Enter below)

Job Title or Classification (Staff RN, Supervisor, etc.)

When is the last time you worked in an acute care setting as an RN? (Please Select) Please select Currently 3 months or less Within the last 6 months Within the last 9 months Within the last year More than 1 year More than 2 years More than 5 years More than 10 years No Acute Care Experience

Vaccinations/Tests: This is for information only, not requirements for volunteering. For most deployments, certain vaccines will be either recommended or required. RNRN cannot guarantee deployment, so we do not recommend getting vaccinations or tests before your deployment is confirmed. However, it is useful to gather proof of vaccinations and research how and where you can get any needed vaccinations and tests on short notice in your area. You do not need to take any action unless you are instructed by RNRN staff to do so for a confirmed deployment.

Current Hep A? yes no

Current Hep B? yes no

Current Typhoid? yes no

Current Tetanus? yes no

Current Influenza? yes no

Current H1N1? (recommended, not required) yes no

Current Meningococcal? yes no

Current Measles, mumps, rubella (MMR)? yes no

Curent Diphtheria/pertussis/tetanus (DPT)? yes no

Current Poliovirus? yes no N/A

Current Varicella (Chickenpox)? yes no N/A (had Chickenpox as a child)

HIV test in last 12 months? (Required for Navy deployments) yes no

TB test in last 12 months? (Required for Navy deployments) yes no

Do you have up to date records of your immunizations? Yes No

Languages:

Do you speak French? yes no

Do you speak Spanish? yes no

Primary Language

List other languages you speak:

Current Specialties/Certifications:

ACLS yes no

PALS yes no

BLS yes no

CCRN yes no

PHN yes no

Other Specialties/Certifications

Other Experience & Travel:

Do you have disaster relief experience? yes no

If Yes, please list what/where:

Do you have a current passport? yes no

Passport Expiration Date

Do you have a passport issued by the United States? yes no (if no, list country below)

If your passport is not issued by the United States, please list the issuing country:

Availability:

Length of Availability (We understand it may be different than length of release time you are ultimately approved for.) (Please Select) Select One 10 days 2 weeks 3 weeks 4 weeks Longer than 4 weeks

If chosen for deployment, you may be given very short notice (1 to 3 days) before the departure date. Is this something you can do? yes no

Deployment is not guaranteed, so it is important to have an ongoing conversation with your hospital regarding flexibility for release time. How long will your hospital/facility be able to approve release time on short notice? (Please Select) Select One 10 days 2 weeks 3 weeks 4 weeks Longer than 4 weeks Still pending approval Not sure

Additional availability notes:

Affiliations:

Are you a National Nurses United (NNU) member? yes no

Are you a California Nurses Association/National Nurses Organizing Committee (CNA/NNOC) member? yes no