Areas of Expertise/Experience/Interest

Foreign Language Proficiency

Please indicate which languages you speak and the degree of proficiency. Select as many as apply. Language Proficiency Click here for proficiency definitions ArabicBengaliBurmeseCambodianCantoneseChineseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHausaHindiIndonesianItalianJapaneseKoreanKurdishLaoMalayNepaliOtherPapua New Guinea PidginPersianPolishPortugueseQuechuaQuicheRussianSerbo-CroatianSpanishSwahiliSwedishTajikTamilThaiTurkishUkrainianUrduVietnameseWolofXhosaYorubaZulu Memorized Elementary Elementary Plus Limited Working Limited Working Plus General Professional General Professional Plus Advanced Professional Advanced Professional Plus Functionally Native ArabicBengaliBurmeseCambodianCantoneseChineseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHausaHindiIndonesianItalianJapaneseKoreanKurdishLaoMalayNepaliOtherPapua New Guinea PidginPersianPolishPortugueseQuechuaQuicheRussianSerbo-CroatianSpanishSwahiliSwedishTajikTamilThaiTurkishUkrainianUrduVietnameseWolofXhosaYorubaZulu Memorized Elementary Elementary Plus Limited Working Limited Working Plus General Professional General Professional Plus Advanced Professional Advanced Professional Plus Functionally Native ArabicBengaliBurmeseCambodianCantoneseChineseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHausaHindiIndonesianItalianJapaneseKoreanKurdishLaoMalayNepaliOtherPapua New Guinea PidginPersianPolishPortugueseQuechuaQuicheRussianSerbo-CroatianSpanishSwahiliSwedishTajikTamilThaiTurkishUkrainianUrduVietnameseWolofXhosaYorubaZulu Memorized Elementary Elementary Plus Limited Working Limited Working Plus General Professional General Professional Plus Advanced Professional Advanced Professional Plus Functionally Native ArabicBengaliBurmeseCambodianCantoneseChineseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHausaHindiIndonesianItalianJapaneseKoreanKurdishLaoMalayNepaliOtherPapua New Guinea PidginPersianPolishPortugueseQuechuaQuicheRussianSerbo-CroatianSpanishSwahiliSwedishTajikTamilThaiTurkishUkrainianUrduVietnameseWolofXhosaYorubaZulu Memorized Elementary Elementary Plus Limited Working Limited Working Plus General Professional General Professional Plus Advanced Professional Advanced Professional Plus Functionally Native ArabicBengaliBurmeseCambodianCantoneseChineseCzechDanishDutchEnglishFrenchGermanGreekHaitian CreoleHausaHindiIndonesianItalianJapaneseKoreanKurdishLaoMalayNepaliOtherPapua New Guinea PidginPersianPolishPortugueseQuechuaQuicheRussianSerbo-CroatianSpanishSwahiliSwedishTajikTamilThaiTurkishUkrainianUrduVietnameseWolofXhosaYorubaZulu Memorized Elementary Elementary Plus Limited Working Limited Working Plus General Professional General Professional Plus Advanced Professional Advanced Professional Plus Functionally Native

Availability To be a participant in this network, you must indicate specific dates when you agree to be on call to respond to emergencies.

Please indicate the specific dates within which you will be available to be on call for emergency contact.
Availability Start Date:	Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 2005 2006 2007 2008
Availability End Date:	Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 2005 2006 2007 2008
Available on a 24 hour notice? Yes No Available on a 48 hour notice? Yes No

Length of Service with an organization is frequently determined by the tasks requested by the organization. Please indicate if there is a strict limit to the time you are available. Availability may be more dependent on the position you seek. Please indicate the duration of assignments you would consider. Check the applicable duration.
2 Weeks	(Applicable only for highly trained individuals involved in rapid assessments, anthropometric surveys, etc.)
2 - 4 weeks
1 - 3 months
3 - 6 months
6 - 12 months
+ 12 months	If greater than 12 months, please explain:

Have you had previous international medical experience? Yes No If Yes, please briefly describe (limit to 250 characters)

Training/Specialty List

Please indicate only those health areas where you have a degree or certification. Please mark all that apply and clarify below if necessary. Where applicable indicate Board Certification/Eligibility (with dates) in the comments section below.

PHYSICIAN Emergency Medicine General Pediatric Family Medicine General Internal Medicine Obstetric-Gynecology Pediatric Internal Medicine Allergy/Immunology Anesthesia Cardiology Critical Care/Intensive Care Dermatology Developmental/Behavioral Pediatrics Emergency Medicine Endocrinology Gastroenterology General Genetics Hematology Infectious Diseases Neonatology Nephrology Neurology Oncology Physical Medicine/Rehabilitation Pulmonology Rheumatology Obstetrics-Gynecology OB/GYN Pathology Forensic General Pediatrics Allergy/Immunology Anesthesia Cardiology Critical Care/Intensive Care Dermatology Developmental/Behavioral Pediatrics Emergency Medicine Endocrinology Gastroenterology General Genetics Hematology Infectious Diseases Neonatology Nephrology Neurology Oncology Physical Medicine/Rehabilitation Pulmonology Rheumatology Preventive Medicine/Public Health Epidemiology/Biostatistics General International Health Maternal Child Health Reproductive Health Tropical Medicine Psychiatry Child General Radiology General Pediatric Surgery General Neurosurgery Ophthalmology Orthopedic Otolaryngology Pediatric Plastic/Reconstructive Thoracic Transplant Trauma Urology PUBLIC HEALTH PROFESSIONAL Nurse Pediatric General Nursing Pediatric ICU/CCU Nurse Pediatric Neonatology Nursing Pediatric Nurse - Midwife Pediatric Nurse (LPN) Pediatric Nurse (RN) Pediatric Nurse Anasthetist Pediatric Nurse Practitioner Pediatric Nurse Sub-Specialist Pediatric OR Nurse Pediatric PICU/NICU Nurse Oral/Dental Pediatric Dental Assistant Pediatric Dental Hygienist Pediatric Dentist Pediatric Oral Surgeon Pediatric Orthodontist Other Health Field Breast Feeding Specialist Child Psychologist Generalist with Pediatric skills Other Pediatric Cytologist Pediatric Emergency Medical Technician/Paramedic Pediatric Laboratory Technician Pediatric Mental Health Counselor Pediatric Nutritionist/General Nutritionist Pediatric Occupational Therapist Pediatric Optometrist Pediatric Physical Therapist Pediatric Physician Assistant Pediatric Radiology Technician Pediatric Respiratory Therapist Pediatric Social Worker Pediatric Speech Therapist Pharmacist Public Health Professional Epidemiology/Biostatistics General International Health Maternal Child Health Reproductive Health Tropical Medicine

Are you Board Certified/Received Degree? Yes No Board Certification Date: Are you Board Certified in more areas than one? Yes No Specialty Board/Degree Specialty Certification Date Subspecialty Board/Degree Subspecialty Certification Date

Skills Please indicate any specific skill sets you have obtained from previous disaster experiences: (Choose all that apply) Advocacy Behavioral and mental health Breast-feeding programs Camp management and/or registration Communicable diseases Curative health programs Health logistics Immunization programs Information Technology Liaison Negotiation/mediation Nutrition and oral rehydration Other Preventative health programs Project/Country/Regional Director Public health assessments/surveys/surveillance Reproductive Health Rights-based programs Sanitation Shelter STDs/HIV-AIDS programs Trauma management in a resource poor environment Unaccompanied minor/orphan programs Water

Do you have military experience? Yes No If Yes, please explain

Do you have your professional medical license? (Photocopy required) Yes No Which State licensed? Has your professional medical license ever been suspended or revoked? Yes No If Yes, please explain

Have you successfully completed a Disaster Training Course? Yes No If Yes, please complete the following: Course Title: Training Organization/Institution: Length of Course: Date: Place Taken: Certification: Please indicate any additional training courses taken. Select all that apply. Management of Complex Humanitarian Emergencies: focus on children and families HELP course Interaction course Public Health Complex Emergencies Training Course (Columbia Univ-IRC-World Educ) IDHA (International Diploma in Humanitarian Assistance) Other

Have you served in a humanitarian emergency? Yes No If Yes, please complete the following based on the most recent: Type: Natural Complex* Technical * Humanitarian relief during war or conflict. When: Region: South/Central America (also Carribean) North America Africa Middle East Europe Asia Australia Oceania In what capacity: Duration:

Have you completed the Neonatal Resuscitation Training Program? Yes No If Yes, please specify the most recent certification date:

Have you completed the Advanced Pediatric Life Support Program? Yes No If Yes, please specify the most recent certification date:

Have you had experience living in crowded/austere conditions successfully? Yes No If Yes, please complete the following: Where: When: Duration:

Have you had experience living in situations of resource scarcity? (ie: food, water, shelter, sanitation) Yes No

Immunization Requirement
Basic	Rec'd	Year Series Completed
Hepatitis A	Yes No Had Illness
Hepatitis B	Yes No Had Illness
Influenza	Yes No Had Illness
Measles (born in or after 1957)	Yes No Had Illness
MMR	Yes No Had Illness
Polio	Yes No Had Illness
Tetanus and Diphtheria (TD)	Yes No Had Illness
Varicella	Yes No Had Illness
Other	Rec'd	Year Series Completed
Immune Globulin	Yes No Had Illness
Japanese Encephalitis/ Tick-Borne Encephalitis	Yes No Had Illness
Meningococcal	Yes No Had Illness
Rabies	Yes No Had Illness
Typhoid	Yes No Had Illness
Yellow Fever	Yes No Had Illness

Documentation of Good Physical and Mental Health

Is there any special kind of accommodations or equipment you require in order to participate in this network? Do you require any medications on a long term and/or an emergency basis? If Yes for any of the above, please list your condition(s) and medication(s).

Three References

(At least one reference should address suitability for disaster relief.) Reference One: Name: Phone: Relationship: Reference Two: Name: Phone: Relationship: Reference Three: Name: Phone: Relationship:

Is there any reason why your performance, suitability or availability may be limited? Yes No If Yes, please explain

Would you be willing to sign a Quality Assurance Form? Yes No

Please enter any additional pertinent information here (limit to 250 characters)

YOUR APPLICATION WILL NOT BE PROCESSED UNTIL ALL INFORMATION IS RECEIVED.
Please forward a copy of the following information to the address listed below: Professional Medical License Curricula Vitae Passport Facesheet The passport facesheet will be used to expedite mobilization. It is your responsibility to ensure that your passport is kept up to date and available on short notice for the organization/agency seeking you.
You will need to choose a password and username. (12 or less alphanumeric characters with no spaces) You will probably want to safeguard this username and password because they will allow you to: Access the network Update the information you entered about yourself later Remove your record from the registry at any time Username Password Confirm Password Thank you for your time and effort in this much needed endeavor. This information is for the sole purpose of the American Academy of Pediatrics Child Disaster Network. American Academy of Pediatrics Section on International Child Health 141 Northwest Point Blvd Elk Grove Village, IL 60007-1098