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2. Last Name
3. First Name
4. Date
   Date
6. Municipal Agency/Organizational Affiliation
   Insert your affiliation (or "none")
8. Contact Information
10. Cell Phone
11. Other Phone
13. Email
15. Other email
17. Emergency Contact Information
19. Name
21. Relationship
23. Contact Phone(s); email
27. PRE-DEPLOYMENT SCREENING
29. The folowing questions regardng your health and pysical conditioooon are being asked to dtermine whether you have any limitations that may affect youp ability to safely perform your duties during this deployment and to assist with your medial care during the deployment, should it become necessary. Answering affirmatively to any question with not necessarily disqualify you from service, so please answer all questions as fully and completly as possible. If you do not understand a question of areunsure how to respond, please discuss it with the volunteer coordinator or incident Safely Officer.
31. Do you feel well today?
    -- Select One --YesNo
33. If "No" why not?
35. Do you have any restrictions of difficulty in your ability to:

    1. Sit for 1 hr or longer
    2. Stand for 1 hr or longer
    3. Bend at the waist
    4. Turn your head
    5. Bend or twist your neck?
    6. Grasp forcibly for a sustained period
    7. Climb stairs or a ladder
    8. Walk rapidly
    9. Reach overhead
    10. Lift or put down a 10 lb load
    11. Lift or put down a 20 lb load
    12. Lift or put down a 50 lb load
    13. Repeatedly move any joint
    14. Twist or move your wrist repetitively
    15. Reach fully forward
    16. Kneel
    17. Run
    18. Jump
    19. Squat
    20. Walk on an uneven surfcace
    21. Get up after seated in a chair
    22. Get up after seated on a floor
    23. Hear normal volume conversations
    24. Need any other special accomodations
37. If you answered "yes" to any of the above, please explain.
39. PLEASE READ: I affirm that the information I have provided is complete and accurate tothe best of my knowledge. I also hereby authorize the release of t his medical information to emergency medical personnel to the extent needed, in the evetn I experience a medical emergency during this deployment.
41. Signature
    Sign or type in first and last name
45. FOR OFFICIAL USE ONLY (to be completed by POD Staff Volunteer Unit )
47. Retrictions Imposed?
    -- Select One --YesNo
49. If Yes, Explain Restrictions
53. Post-Deployment Screening
55. Do you feel well?
    -- Select One --YesNo
57. If "No" exlain why
59. Did you expereince an injury or illness while deployed?
    -- Select One --YesNo
61. If "Yes" explain what and how it happened
63. Did you report this incident to the Safety Officer or other official?
    -- Select One --YesNONA
65. If "No" why was is not reported. If reported, to whom was it reported?
67. Did you receive any on-site of off-site treatment for and injury or illness?
    -- Select One --YesNoNA
69. If "YEs" describe the treatment
71. I affirm that the above information is complete and accurate to the best of my kknowledge. I also affirm that I have been informed of appropriate procedures for reporting any injuries od ilnesses that I may experience in the future that I feel may be related to my response activities today.
73. Team Member Sign or Print First and Last Name
74. Date and TIme
    Date and TIme

    Date and TIme
76. Staff Screener sign of print first and last name
77. Date and TIme
    Date and TIme

    Date and TIme
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

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