GRMC Medical Volunteer Form

GRMC Medical Volunteer Form
Thank you for joining us. We may need the help of qualified health professionals and related professionals to supplement our current hospital capacity temporarily as we deal with a potential surge of COVID-19 patients. If you are willing to support the GRMC’s efforts in a volunteer capacity, please let us know by completing this survey regarding your experience and qualifications. GRMC does not guarantee positions for any medical personnel, but will contact you should the need arise.
Medical Volunteer Information
Name *
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age *
Are you a licensed medical professional? *
Emergency contact person

First Name Last Name
Emergency contact phone number

Area Code Phone Number
Scope of Care
Type of Provider *
Specialty or Care Area *
What type of patient care experience do you have? *

Ventilators Palliative Care Vasopressor drips Intubation Dialysis machines (CRRT or CVVH) Central lines Inserting IVs General medical inpatient care General medical outpatient care Labor & Delivery Medication preparation / hanging drips
Please indicate highest level of patient care *
What electronic health record systems do you feel comfortable adopting if necessary? *

None Meditech Athena
Work Status *
Matching with Need
Please indicate highest number of hours you are able to work in a day *
Are you able to volunteer full-time? *
Will your employer continue to pay you to support New Mexico COVID-19 response efforts? *
Other Information
Please indicate if you have any pre-existing conditions, especially any with COVID-19 increased risk *
Preferences, limitations, abilities, etc.
Please provide any other information that is relevant as the GRMC builds healthcare workforce capacity in this regard, especially experience with infectious diseases, respiratory conditions, critical care, or emergency medical services or care.
Type a question
Note: If you don’t see a confirmation after clicking “Submit”, please scroll up and enter missing information as highlighted.
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GRMC Medical Volunteer Form

Medical Volunteer Information

Scope of Care

Matching with Need

Other Information