Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have privileges at Michael Garron Hospital? *

Yes

No

ACLS up to date? *

Yes

No

If yes, please indicate date of completion.

MM

DD

YYYY

ATLS up to date? *

Yes

No

If yes, please indicate date of completion

MM

DD

YYYY

Previous Hospital Emergency Room Experience? *

Yes

No

Previous Hospitalist experience? *

Yes

No

Previous Palliative Care experience? *

Yes

No

N95 Mask Size (if known) *

Unknown

3M 8110 S

3M 8210

3M 9210 P

3M 1860S

3M 9105s

3M 1860 M/L

3M 1870 P

3M 9105

Please check any areas listed below where you would be prepared to work if the need arises. *

For some of these areas informal training and backup supports is available.

EMERGENCY SERVICES

HOSPITALIST (ACUTE CARE)

HOSPITALIST (CHRONIC CARE)

PALLIATIVE CARE ( HOSPITAL/HOME)

VIRTUAL HOME CARE

HOME VISITING

LONG TERM CARE HOME SUPPORT/OUTREACH