DRN Database Form

DRN Database Form

Disaster Response Network -- Member Data Form

Contact Information
First Name:		Initial:
Last Name:		Degree:
Phone 1:		Phone 2:
Phone 1 Type:	home cell work	Phone 2 Type:	home cell work
E-mail:
APA Member #:
Address:
Address cont.:
City:
State:	\| Zip: \|

Professional Information
License Type	State	License Number	License Current?



Do you have malpractice insurance?
Are you working or retired?
Please list your current primary occupation: (e.g. private practice; teaching; consulting; institutional practice; graduate student, etc...)

Training & Credentials
Disaster Mental Health Training:			Year of completion:
Red Cross Foundations of Disaster Mental Health
Other
Other
Are you a Red Cross Instructor for Disaster Mental Health Services?
Current Red Cross DMH Function:		Service Associate Supervisor Manager Administrator
Other crisis/trauma/disaster-related organizational affiliations:


Disaster Mental Health Services Experience
Please list up to five disaster response experiences within the past 10 years:

Type of incident	Organization/Location (name;city,state)	Function Served	Days worked	Year
Ex.: Flood	ARC Arlington Chapter; Arlington, VA	Service Associate	2	2007






Your preferred disaster response functions: (please check all that apply)
On-site services with survivors Children - teens - adults - seniors - all On-site services with relief workers Research DMH Planning and Development Emergency Operations Centers Supervision with psychology graduate students Other (please specify)


Language / Special Populations
Languages in addition to English:
Language:	Speaking ability	Reading/Writing ability



Please describe any specific special populations with which you have expertise:
Adolescents Aircraft Disasters Children College Corporate Cultural - Specify Disabled - Specify Emergency Services Personnel Families		Medical Setting Military PTSD Religious - Specify Rural Seniors Serious Mental Illness Trauma/Abuse Vets
Other
Thank you for completing this form. The information you provide will enable us to maintain a national database of psychologists with training in disaster work. We will use this information to communicate with you and to assist the American Red Cross and other organizations in mobilizing DRN members for disaster relief operations.

© 2008 American Psychological Association
Practice Directorate
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Phone: 202-336-5800 • TDD/TTY: 202-336-6123
Fax: 202-336-5797 • Email
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