County Veterinary Emergency Response Personnel Application

County Veterinary Emergency Response

Personnel Application-19

Name___________________________________________________________________

Last First MI

Home Address____________________________________________________________

Number and Street City Zip

Home Phone ( ) ____________________ Fax ( ) _____________________

Pager ( ) _________________________ Cell ( ) _____________________

Work Address____________________________________________________________

Number and Street City Zip

Work Phone ( ) ____________________ Fax ( ) ____________________

May we call you at work? ‘ Yes ‘ No

Are you licensed and accredited in California? ‘ Yes ‘ No

What is your primary area of expertise?

‘ Companion animals (‘ dogs ‘ cats ‘ pocket pets ‘ house exotics)

‘ Large animals (‘ cattle ‘ swine ‘horses ‘ cervidae ‘ camelids ‘ ratites)

‘ Poultry (‘ chickens ‘ turkeys ‘ ducks ‘ geese)

‘ Farm Exotics (‘ ratites ‘camelids)

‘ Other: _______________________________________________

Do you have a mobile clinic or equipment? ‘ Yes ‘ No

Are you prepared to use it during a disaster response? ‘ Yes ‘ No

Medical Insurance Carrier ___________________ Policy Number ___________________

Driver’s License Number ___________________ Expiration Date _____/______/_______

Vehicle License Plate Number _______________ Description _______________________

Trailer License Plate Number ________________ Description _______________________

Do you have Standardized Emergency Management System (SEMS) training? ‘ Yes ‘ No

Disaster Training or Experience______________________________________________

_______________________________________________________________________

________________________________________________________________________

Signature ____________________________________________ Date ____________

Approved by _________________________________________ Date ______________

^{19-Adapted from the Indiana State Annex for Veterinary
Emergencies Committee.

__________________

Draft On- line for

Nevada Animal Disaster Preparedness Guide

The draft was provided by the California Office of Emergency Services.

http://www.cdaf.ca.gov/programs/disasterprep.htm

Back to Draft
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