Emergency Preparedness

Appendix Q.1 Volunteer Management

THIS PAGE IS DESIGNED FOR HOSPITAL USE ONLY

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Licensure verified – current no restrictions Hospital affiliation verified – no restrictions

Copy of current licensure

Copy of current certification(s)

Copy of government issued Photo identification

Copy of professional liability insurance

Criminal Background check (incl. OIG) – no exclusions

NPDB queried – no adverse actions

Date verified: __________ Primary Source of verification: _______________ Initials: _______________ Department: ___________

Recommend temporary emergency privilege / status be granted in the specialty / area of: ________________________________________________

Date granted: _______________

Expires on: _____________

Authorization Signature: __________________________ Name: _________________________________

Date: ______________________ Extension: _________________

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