Medical Staff Response for COVID-19
Last Name
First Name
E-mail Address
Cell Number
Medical Background
--Select Background--
Physician
Nurse Practitioner
Physician Assistant
Other
Please specify other Medical Background
Practice Name
Practice Location
Which states are you currently licensed in? (check all that apply)
Vermont
New York
Other
Please list any other states you are licensed in
Do you have experience working with Epic (Electronic Health Record System)?
Yes
No
Which age groups are you experienced with caring for? (check all that apply)
<1
1-18
Adult
Complex Geriatric
Which areas are you comfortable providing support for? (check all that apply)
Inpatient medical floor
Critical Care area
Emergency department/Triage
Ambulatory Care
Palliative Care
Telephone/Telemedicine Clinical Support
Administrative Support
Where do you currently have privileges? (check all that apply)
University of Vermont Medical Center
Central Vermont Medical Center
Porter Medical Center
Home Health & Hospice
Alice Hyde Medical Center
Champlain Valley Physicians Hospital (CVPH)
Elizabethtown Community Hostpital
Other
Please list Others
University of Vermont Health Network Section
Your Health Network User ID (e.g. "M"# or @uvmhealth.org address)
Department
--Select Organization --
Anesthesiology
Children’s
Family Medicine
Medicine
Neurology
Orthopedics
Pathology
Psychiatry
Radiation Oncology
Radiology
Surgery
Women’s
Division (if applicable)
Medical Staff Office Status
--Select Status --
Active
Courtesy
Affiliate
Honorary
Do you have any barriers we should be aware of?