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2020 TB Free Chuuk Volunteer Form - Final

TB+Leprosy Free Chuuk
Volunteer Form

Thank you for considering a volunteer mission to Chuuk.

Please enter your contact information below.

First Name

Last Name

Title

Organization Name

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address

Phone Number

Mobile Phone

Check all certifications and credentials that apply.

Physician (MD/DO)
Nurse (RN)
Nurse Practitioner (FNP)
Physician Assistant (PA)

Epidemiologist (Epi)
Radiology Technologist (RadTech)
Other - Write In Please enter an 'other' value for this selection.

How many years of TB program experience do you have?

Which of the healthcare-related skills listed below do you have? Check all that apply.

Interpret chest X-rays (CXRs)
Clinically manage TB clinic patients
Clinically manage LTBI patients
Conduct Hansen’s Disease screening
Case-manage TB clinic patients
Case-manage LTBI patients
Manage directly observed therapy (DOT) staff
Manage contact investigation staff

Collect sputum (natural/induced)
Place/read tuberculin skin tests (TSTs)
Collect point-of-care-glucose or A1c
Take X-rays
Assist X-ray (positioning)
Collect, manage, and organize data for epidemiological analysis
Provide epidemiologic analysis and interpretation of data to inform TB elimination efforts
Other - Write In Please enter an 'other' value for this selection.

Comments

Have you lived or worked overseas for more than 1 month?

If “yes,” for how long?

If “yes,” in which country?

Which volunteer groups do you prefer to join?
Rank them from 1 to 10, 1 being your 1st choice, 2 being your second choice, etc.
Please select each ranking number only once--there should be only one "1" entered, one "2" entered, etc..
Please provide a rank ONLY for the groups you are able and willing to join.
NOTE: Start and End travel dates may shift slightly due to flight arrangements.

Space Cell	1	2	3	4	5	6	7	8	9	10	N/A
Group A – Arrive Chuuk on March 9, Depart Chuuk on April 1	1	2	3	4	5	6	7	8	9	10	N/A
Group B – Arrive Chuuk on March 30, Depart Chuuk on April 22	1	2	3	4	5	6	7	8	9	10	N/A
Group C – Arrive Chuuk on April 20, Depart Chuuk on May 13	1	2	3	4	5	6	7	8	9	10	N/A
Group D – Arrive Chuuk on May 11, Depart Chuuk on June 3	1	2	3	4	5	6	7	8	9	10	N/A
Group E – Arrive Chuuk on June 1, Depart Chuuk on June 24	1	2	3	4	5	6	7	8	9	10	N/A
Group F – Arrive Chuuk on June 22, Depart Chuuk on July 15	1	2	3	4	5	6	7	8	9	10	N/A
Group G – Arrive Chuuk on July 13, Depart Chuuk on August 5	1	2	3	4	5	6	7	8	9	10	N/A
Group H – Arrive Chuuk on August 3, Depart Chuuk on August 26	1	2	3	4	5	6	7	8	9	10	N/A
Group I - Arrive Chuuk on August 24, Depart Chuuk on September 16	1	2	3	4	5	6	7	8	9	10	N/A
Group J - Arrive Chuuk on September 14, Depart Chuuk on October 7	1	2	3	4	5	6	7	8	9	10	N/A

Comments

1. If your requested time is full, are you willing to be placed on a list to serve as a back-up volunteer to step in for cancellations, family emergencies, etc?

2. Special Requests: (travel partner, family)

This is hard work, and most volunteers are exhausted after their three-week volunteer mission. For this activity, preference may be given to those who are willing to work in Chuuk for a longer period of time.

3. If you can extend your time in Chuuk, please enter below your possible arrival and departure dates between March 9 and October 7.

Space Cell	Arrival Date	Departure Date
Group A	Arrival Date	Departure Date
Group B	Arrival Date	Departure Date
Group C	Arrival Date	Departure Date
Group D	Arrival Date	Departure Date
Group E	Arrival Date	Departure Date
Group F	Arrival Date	Departure Date
Group G	Arrival Date	Departure Date
Group H	Arrival Date	Departure Date
Group I	Arrival Date	Departure Date
Group J	Arrival Date	Departure Date

Comments

Thank you for completing this form.