Emergency Preparedness
Appendix Q.1 Volunteer Management
THIS PAGE IS DESIGNED FOR HOSPITAL USE ONLY
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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