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Arkansas Nurses Emergency Response System
Please fill out the following questionnaire as accurately as possible. If you do not have information for a particular item, please leave the box empty.  You will be able to update your information in the future.
 Personal Information
First Name:
Middle Name:
Last Name:
RN/LPN License No.:
Designation/Credentials:
 Work Information
Address:
City:
State:
Zip Code:
County:
Phone Number:
Example: 501-555-5555
Fax Number:
Example: 501-555-5555
Pager Number:
Example: 501-555-5555
Cell Phone Number:
Example: 501-555-5555
eMail Address:
Example: jane@aol.com
 Home Information
Address:
City:
State:
Zip Code:
County:
Phone Number:
Example: 501-555-5555
Fax Number:
Example: 501-555-5555
Pager Number:
Example: 501-555-5555
Cell Phone Number:
Example: 501-555-5555
eMail Address:
Example: jane@aol.com
 Prefered Daytime Contact Method
Please select options from pull down menu.
Option 1:
Option 2:
Option 3:
 Prefered Night or Weekend Contact Method
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Option 1:
Option 2:
Option 3:
 
 Notification
Specify advance notification requirements. Check all that apply.
Less than 24 Hours: 24 to 48 Hours:
2 to 5 Days: 1 Week:
1 to 2 Weeks: 30 Days:
 
 Availability
Specify how long you will be available. Check all that apply.
Less than 24 Hours: 24 to 48 Hours:
2 to 5 Days: 1 Week:
1 to 2 Weeks: 30 Days:
Indefinitely:    
 Geographical Response Areas
Specify places that you are willing to travel.
Local Area:
Statewide:
Surrounding States:
Nationwide:
Worldwide:
 Language Expertise
Check all languages that apply.
Arabic: Vietnamese:
Chinese: Spanish:
Japanese: French:
Korean: American Sign Language:
Other Language 1:
Other Language 2:
 Military Service
Please check and provide dates of enlistment to all that apply.
Active Military:  
From Date: mm/yyyy To Date : mm/yyyy
     
Military Reserve:  
From Date: mm/yyyy To Date : mm/yyyy
     
National Guard:  
From Date: mm/yyyy To Date : mm/yyyy
 Employment Setting
Check all that apply.
Hospital: Home Health:
School of Nursing: Physician/Dentist Office
School/College of Health: Community/Freestanding Clinic:
Long Term Care:    
Other:
 Emergency Training
Check all appropriate credentials that apply. 
Advance Cardiac Life Support:
Advance Trauma Life Support:
Pediatric Advanced Life Support:
Neonatal Advanced Life Support:
Pre-Hospital Trauma Life Support:
Basic Cardio Pulmonary Resuscitation:
Emergency Medical Technician:
Paramedic:
Red Cross Disaster Training:
Trauma Nurse Core Curriculum:
Nuclear, Biological, Chemical Training:
Other:
 Clinical Expertise
Check all appropriate credentials that apply. 
Adolescent:
Allergy/Immunology:
Burns:
Cardiac:
Chemical Dependency/Substance Abuse:
Communicable Disease:
Dermatology:
Emergency:
Geriatrics:
Immunization:
Infection Control:
Intensive Care:
Medical/Surgical:
Neonatal:
Obstetrics:
Oncology:
Opthalmology:
Orthopedics:
Pathology/Forensics:
Pediatrics:
Psych/Mental Health/Counseling:
Public Health or Preventive Medicine:
Radiology:
Rehabilitation:
Trauma:
Other:
 Additional Information
Please provide any additional information for our records. 

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