OFRD Officer Questionnaire

PHS Serial Number:
First Name:
Last Name:
Response Team Choice:  
For details on response team composition:  All Teams  RDF  SERT  APHT  MHT 

Select ALL of the deployment roles for which you qualify:
Admin/Finance Dentist Dietitian Disaster Engineer
EMT Environmental Health Epidemiologist Food Safety
Hazardous Materials/Hazardous Waste IT/Commo/Intel Liaison Logistics
Medical Records Medical Technologist Mental Health Nurse
Nurse Practitioner Occupational Health/Industrial Hygiene Operations Optometrist
Pharmacist Physician Physician Assistant PIO/Risk Communication
Planning Preventive Medicine Response Team Leader Safety Officer
Strategic National Stockpile Officer Therapist Veterinarian


Select the BEST description of your current duty assignment:
Administrative Air Quality Certified Nurse Anesthetist Dental Hygienist
Dentist Dietitian/Nutritionist Emergency Operations Engineering
Epidemiology Facilities Design/Management Food Safety and Security General Environmental Health
Hazardous Waste/Materials Manager Hospital Industrial Engineer Industrial Hygiene
Information Technology Inpatient Institutional EH/IH Logistics
Long Term Nursing Care Mental Health Nurse Nurse Practitioner
Occupational Health Outpatient Patient Care Pharmacist
Physician Assistant Physician, Other Specialty Physician, Primary Care Preventive Medicine
Psychiatrist Psychologist Public Health Radiological Health
Reference Laboratory Regulatory Research Safety
Social Work/Case Worker Solid Waste Management Toxicology Veterinarian
Veterinary Medicine Water/Waste Water Management

Select all previous job experience and specialties:
Administration Aerospace Allergy & Immunology Anesthesiology
Animal, Laboratory Animal, Large/Equine Animal, Poultry Animal, Small
Animal, Zoo/Exotic Anti-coagulation Asthma/ Pulmonary Blood Banking
Blood Borne Pathogens Burn and Trauma Care Cardiology Case Management
Certified Nurse Anesthetist Chemistry Clinical Audiology / Speech Pathology Clinical Dentistry
Clinical Optometry Clinical OT Clinical Pharmacy Clinical PT
Clinical Veterinarian Comprehensive General Practice Critical Care Dental Hygienist
Dermatology Diabetes Educator Contract Officer COTR
Budget Management IMPACT Card Auth Dietitian/Nutritionist Emergency Medicine
Emergency/Shelter Sanitation Endocrine Endodontics Engineering, Biomedical
Engineering, Civil Engineering, Electrical Engineering, Environmental Engineering, Mechanical
Engineering, Nuclear Engineering, Systems Engineering, Water Resources Epidemiology
Family Medicine Food Safety and Security Forensic Odontology Gastroenterology
General Dentistry General Environmental Health Hazardous Waste/Materials Manager Hematology/Oncology
Hospital Dentistry Hyperlipidemia Industrial Hygiene Infectious Disease
In-Patient Laboratory In-Patient Med Records Administrator Institutional EH/IH Intensive Care/Telemetry
Internal Medicine IV/ TPN Laboratory, Outpatient Logistics
Med/Surg Medical Genetics Mental Health Mental Health Nurse
Microbiology/Animal Bio-safety/Pathology Neonatology Nephrology Neurology
Nuclear Medicine Nurse Anesthetist Nurse Midwife Nurse Practitioner
Ob/Gyn Occupational Health Occupational Health Nurse Occupational Medicine Physician
Occupational Therapist Oncology Operating Room Ophthalmology
Oral and Maxillofacial Surgery Oral Medicine Orthopedics Other Specialty Physician
Otolaryngology Outpatient Med Records Administrator Pathology Pediatric Dentistry
Periodontics Physical Medicine and Rehabilitation Physician Assistant Preventive Medicine
Primary Care Physician Psychiatric Psychologist Public Health Consultant
Public Health Dentistry Public Health Nurse Public Health Physician Public Health Veterinarian
Pulmonary Radiological Health Reference Laboratory Regulatory
Research Clinical Research Laboratory Research Public Health Research Veterinarian
Rheumotology Safety Officer Social Work/Case Worker Solid Waste
Substance Abuse Surgery Toxicology Urology
Veterinary Medicine VMAT Water/Waste Water

Select ALL of the training that you have completed below:
APhA – Vaccination Certification Program Applied Food Safety Sanitation Course ARC – Disaster Mental Health ARC – Disaster Nursing
ASPA – Public Information Officer Training Burn and Trauma Course CDC – EIS CDC – Preventive Medicine Residency
DoD/DMRTI – Combat Casualty Care Course (C4) DoD/DMRTI – Homeland Security Medical Executives Course DoD/DMRTI – Joint Operations Medical Management Course DoD/OFRD – CHART
DoD/USAMRIID – Medical Management of Chemical and Biological Casualties Course FDA – Food Code Course FEMA – F719 Incident Safety Officer Course FEMA/EMI – IS 100
FEMA/EMI – IS 200 FEMA/EMI – IS 300 FEMA/EMI – IS 400 FEMA/EMI – IS 700
FEMA/EMI – IS 800 Forensics (AFIP or Univ of Texas) Life Safety Code Course Mass Fatality Training
OFDA – DART OPHEP – Administration/Finance Training Course OPHEP – Burn Nurse Training OPHEP – SERT Training Course
OSG/OFRD – Emergency Coordinator Augmentee Training OSG/OFRD – Liaison Officer Training OSG/OFRD – Mental Health in a Disaster Training OSG/OFRD – Response Team Leadership Course
OSG/OFRD – Vaccination Training Program PTSD Training Risk Communication Training SNS/Mass Prophylaxis Training

Select ALL current certifications and registrations:
ABVT ACLAM ACLS ACVIM ACVP ACVPM
ACVS Amateur Radio License APhA Immunization Certification ARNP ASCP ATLS
AVECC Certified Network Engineer CFSP CHMM CHP CIH
CNS Confined Space Entry CSP Diabetes Educator Certification EMT EMT-P
FDA, Level 1 Investigator Certification First Responder HAZCOM HAZMAT HAZWOPER HIMA Registration
ICS Mental Health Provider Certification NCA OSHA Respiratory Protection PALS PE
REHS RHSP RHSS RN RS Specialty Nurse Certification
USDA- FADD Certification USDA Veterinary Accreditation

Select the mission roles that you have filled during your last five (5) deployments (including OFRD and agency):
Admin/Finance Admin/Finance Chief Animal Shelter Veterinarian Clinical Dentist
Clinical Optometrist CMO Dental Hygienist Dentist
Dietitian/Nutritionist Disaster Engineer Emergency/Shelter Sanitation Emergency Operations Center
EMT Engineering Epidemiology Equine/Large Animal Veterinary Care
ERT-A Member Food Safety and Security Food Service Forensic Odontologist
General Environmental Health Immunization Team Incident Commander Industrial Hygiene
In-Patient Care Team Inpatient Medical Technologist Institutional EH/IH IT/Commo/Intel
IT/Commo/Intel Section Chief Liaison Liaison, DMORT Liaison,EOC
Liaison,NRCC Liaison,RRCC Liaison,SOC Liaison,State EOC
Logistics Logistics Chief Medical Records Administrator Mental Health Collaboration
Mental Health Provider Nurse Nurse Practitioner Occupational Safety and Health
OpDiv Emergency Operations Operations Operations Chief Outpatient Care Team
Pharmacist Planning Planning Chief POD Nurse
POD Pharmacist POD Physician Assistant Preventive Medicine Primary Care Medical Team
Public Health Public Information Officer / Risk Communications Regulatory Rescue/Recovery Small Animal Veterinary Care
Safety Officer SERT CMO SERT Commander SERT Dep Commander
SERT General Staff SNS/FEMA Support Solid Waste Special Needs Shelter
Specialty Physician Team Leader Therapist USDA Field Operations
Veterinarian Water/Waste Water Zoonotic Disease Outbreak
Not previously deployed
 

Describe your supervisory experience below:

How many personnel currently report directly to you at your job?

none 1 – 3 4 – 7 8 or more

How many total personnel are currently under your coordination at your job?

none 1 – 10 11 – 39 40 or more

How many personnel reported directly to you during your last 5 deployments?

Deployment #1 Deployment #2 Deployment #3 Deployment #4 Deployment #5
none none none none none
1 – 3 1 – 3 1 – 3 1 – 3 1 – 3
4 – 7 4 – 7 4 – 7 4 – 7 4 – 7
8 or more 8 or more 8 or more 8 or more 8 or more

How many total personnel were under your coordination during your last 5 deployments?

Deployment #1 Deployment #2 Deployment #3 Deployment #4 Deployment #5
none none none none none
1 – 10 1 – 10 1 – 10 1 – 10 1 – 10
11 – 39 11 – 39 11 – 39 11 – 39 11 – 39
40 or more 40 or more 40 or more 40 or more 40 or more

 

Please indicate any of the following experience:

DoD S/G/N/J-1 (Personnel)
DoD S/G/N/J –3 (Operations)
DoD S/G/N/J –4 (Supply and Logistics)
DoD S/G/N/J –5 (Planning)
DoD S/G/N/J – 6 (Command/Control/Communications/Civil Relations)
Morgue Operations
NDMS Management Support Team

 

CLINICAL PROVIDERS - Select all clinical populations that you can serve:

Adolescents Adults Animals Special Needs
Geriatrics Neonates Pediatrics

 

CLINICAL PROVIDERS - Select all clinical populations that you can serve:

Direct Patient Care Ambulatory Care Inpatient Setting Long Term Care
Health Dept Primary Care Setting Points of Distribution (POD) Immunization





 

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This page was last modified: 05/14/2009 07:03 PM