Request MRC Support – Medical Reserve Corps

Requestor Information

Requestor Name*

Title*

Requesting Organization Name*

Requesting Department Name

Phone*

Email*

Requestor Relation*

Community Partner
Internal Public Health District
Local Government
VDH Central Office

General Request Information

Support Request Type*

Exercise
Training
Emergency Response
VDH Central Office Support

Support Request Type*

Exercise
Training
Community Event
Emergency Response

Event, Training, Exercise or Emergency Name:*

Purpose of Support:*

Desired Outcome:*

This field is hidden when viewing the form

Location Name*

Location Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Locality where the event will take place*

Support Start Date*

Start Time*

:

Support End Date*

End Time*

:

Estimated Time Commitment to Fulfill Support Request*

Ex: 32 hrs total, 5 hrs bi-weekly, 20 hrs weekly, etc.

If the Event is over an extended period of time, are shifts available?*

Yes
No

Is the event*

Indoors
Outdoors

Is there a planned date if the event is cancelled due to bad weather?*

Yes
No

Is there a specific location for parking?*

Yes
No

Will you provide

EVENT OR EXERCISE Request Details

Have you ever hosted this Event or Exercise before?*

Yes
No

Estimated number of attendees*

What special population will this event serve*

Who is sponsoring the Event or Exercise

Type of services requested*

Blood Pressure
Weight/BMI
Basic First Aid

Type of education requested*

Emergency Preparedness
Chronic Disease (Hypertension, Diabetes, Healthy Living)
Opioid/Addiction
Vector borne illnesses – Lyme or Zika
Cover Your Cough, Wash Your Hands
Other:

TRAINING Request Details

Type of training requested (offerings will vary based on area and trainer availability)*

REVIVE! Training: This training covers understanding opioids, how opioid overdoses happen, risk factors for opioid overdoses, and how to respond to an opioid overdose emergency with the administration of Naloxone.
REVIVE! Train the Trainer: This training teaches individuals how to conduct trainings and is appropriate for individuals who intend on leading trainings in the community.
Narcan Dispensing
Until Help Arrives Training: Trauma is the leading cause of death for Americans under age 46. Life-threatening injuries require immediate action to prevent an injured person from dying. Those nearest to someone with life threatening injuries are best positioned to provide first care. The Until Help Arrives training teaches community members to save lives by taking simple actions immediately.
Emergency Preparedness
Other

Will you provide

Projector
Computer
Copies of needed handouts
Food for attendees

Volunteer Request Information

How many non-medical volunteers are needed?*

What roles with the non-medical volunteer fill?*

Are there service descriptions or job action sheets available for the non-medical positions?

Yes
No

Is there specific certifications, knowledge, skills or abilities needed to perform the tasks?

Yes
No

How many medical/public health professional volunteers are needed?

Are there service descriptions or job action sheets available for the medical positions?

Yes
No

What types of licensed health care professionals are needed? (please provide a number of each)

Is there specific medical or public health certifications, knowledge, skills or abilities needed to perform the tasks?

Are there different times requested for specific volunteer types?

Volunteer Supervision

Will you be providing supervision for the volunteers for the requested event, activity, exercise or emergency?*

What is the name of the supervisor the volunteers will be reporting to?

What is the contact phone number for the supervisor?

What is the supervisor’s email?

If you have previously discussed this request with anyone at the Virginia Department of Health, please share their name.