Emergency Preparedness

Appendix Q.1 Volunteer Management

Kern Medical Emergency / Disaster Temporary Privileges / Status Request Form Record of Patients Seen By Licensed Practitioner During Disaster / Emergency

Name of Volunteer Practitioner: ____________________________

Name of Assigned KERN MEDICAL Staff Member______________________

Department / Area of Assignment: __________________________

License #: ________________________________ The following patients were seen and/or treated during this emergency/disaster by this volunteer practitioner: Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________ Pt: ________________________ Med Rec #: ________________________

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