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Medical Volunteer Skill Level Survey

To better serve you as a Medical Reserve Corp volunteer, please take a moment to fill out the following questionnaire. Your personal file will then be updated and it will allow us the opportunity to contact you according to upcoming training and events.

Your time is greatly appreciated. Thank you.

Injection Skills

Name *
Address
City		State		Zip
Telephone number *
e-mail address

* - required contact information fields.

Are you comfortable giving injections to all age groups?

Yes No

If yes, please explain your experience and type of work environment that you administered injections.

If no, would you feel comfortable and willing to participate with "just-in-time" training if needed to administer injection?

Yes No

Please explain:

What types of injections do you have experience administering:

	How recently have you given these injections?
	Level I 0-2 years	Level II 2-5 years	Level III > 5 years
IM (intramuscular)
Subcutaneous (Subq)
Bifurcated
None of the above

Do you have experience administering pediatric injections? (0-12 years)

	How recently have you given these injections?
	Level I 0-2 years	Level II 2-5 years	Level III > 5 years
IM (intramuscular)
Subcutaneous (Subq)
Intradermal
None of the above

If you are capable of starting an IV, please answer the following:

Are you comfortable starting an IV�for all age groups?

Yes No

	How recently have you administered an IV?
	Level I 0-2 years	Level II 2-5 years	Level III > 5 years
Adults (>12 years)
Pediatrics (0-15 yrs)

If you are capable of performing a blood draw, please answer the following:

	How recently have you performed a blood draw?
	Level I 0-2 years	Level II 2-5 years	Level III > 5 years
Adults (>12 years)
Pediatrics (0-15 yrs)

Last Modified: Wed Jan 7 08:34:02 2009

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