NZMAT Registration of Interest Form

NZMAT Registration of Interest Form

If you would like to register your interest in volunteering to assist with the provision of services (should an emergency response effort be required), please complete the following Registration Form ensuring that all mandatory field (marked *) are completed to enable successful submission.

Please note that by registering as a potential volunteer, you acknowledge that you hold a NZ recognised practicing certificate or equivalent credentials where necessary to provide the health service(s) you are volunteering.

This Registration Form is fairly comprehensive and you are required to provide:

• Personal details

/ -such as name and gender

• Contact details

/ -such as address and telephone numbers

• Professional details

/ -such as health professions, registration numbers, annual practicing certificate, graduate qualifications and speaking languages

• Drivers licence details

/ -such as type, number and expiry (if applicable)

• Relevant experience details

/ -Such as work experience in developing countries, emergency management training and deployment and memberships / affiliations with other health disaster emergency response organisations

• Work status details

/ -Such as citizenship and passport information if you indicate that you are available for overseas deployment

• Medical details

/ -Such as vaccinations and any medical conditions (please note that if you have any current medical conditions that could affect your ability to function effectively as a team member during a response – your application may not be accepted)

• Reference details

/ -The names and contact details of 2 references

• Emergency contact details

/ -The name and contact details of at least 1 person

• Agreement and confirmation details

Questions regarding the registration process may be directed to the NZMAT Programme Manager:

Name: / Judy Fairgray
Contact number: / 021 227 4830
Email: /
Physical address: / Counties Manukau District Health Board
C/- Pacific Health Development
Private Bag 93311
Otahuhu
Auckland 1640

Upon completion of the Registration Form, it may be either scanned and emailed or posted to the NZMAT Programme Manager

PERSONAL DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Date (day/month/year)
Title * /  Mr /  Mrs /  Ms /  Miss /  Doctor
First Name *
Middle Name(s)
Last Name *
Gender * /  Male /  Female
Ethnicity /  NZ European
 NZ Maori
 Other European / Define:
 Pacific Peoples / Define:
 Asian / Define:
 Middle Eastern / Define:
 Latin American / Define:
 African / Define:
 Other / Define:
CONTACT DETAILS
When completing this section, please ensure that you provide the best details to easily contact you.
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Contact Details – Phone numbers * / Home
Work
Work mobile
Personal mobile
Contact Details – Email Address * / Personal
Alternative Personal
Work
Contact Details – Address * / Number and Street
Suburb
City
Postcode
EMPLOYMENT DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Current Employment * /  Agency / Provide Name :
 DHB / Provide Name :
 General Practice / Provide Name :
 Public Health Unit / Provide Name :
 Pharmacy / Provide Name :
 Self-employed in NZ Health Field
 Self-employed in NZ Non-Health Field
 Employed in NZ Non-Health Field / Provide Name :
 Employed outside NZ in Health Field / Provide Name :
 Employed outside NZ in Non-Health Field / Provide Name :
 Not Currently Employed
Has your employer signed the ‘Employer’s Acknowledgement Form’? * /  Yes /  No /  N/A
Comments
Attach signed Employer’s Acknowledgement Form *
PROFESSIONAL DETAILS
This section allows you to register the professions which you are CURRENTLY qualified to do (if qualification are relevant)
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Professional Category – Main * / Administration / Define:  DHB /  General Practice
 Allied Health / Define:
 Ambulance Paramedic / Level:
 Caregiver /  Aged Care /  Palliative Care /  DSS
 Doctor – Anaesthetist
 Doctor – General Practitioner
 Doctor – General Surgeon
 Doctor – Obstetrician
 Doctor – Orthopaedic Surgeon
 Doctor – Paediatric Surgeon
 Doctor – Plastic Surgeon
 Doctor – Other Surgeon / Define:
 Doctor – Paediatrician
 Doctor – Pathologist / Disaster Victim Identification
 Doctor – Psychiatrist
 Doctor – Public Health
 Doctor – Radiologist
 Doctor – Registrar / Define:
 Doctor – RMO / House Officer / Define:
 Emergency Manager
 Emergency Management Logistician
 Enrolled Nurse / Define Speciality
 Midwife /  LMC /  Hospital
 Pharmacist
 Psychologist
 Public Health /  HPO / MOoH /  Other –define:
 Radiographer
 Registered Nurse – District / Community
 Registered Nurse – ED / Emergency Care
 Registered Nurse – Flight Nurse
 Registered Nurse – General Practice Nursing
 Registered Nurse – General Medical
 Registered Nurse – General Surgical
 Registered Nurse – ICU
 Registered Nurse – Mental Health
 Registered Nurse – Orthopaedic
 Registered Nurse – Paediatric
 Registered Nurse – Public Health
 Registered Nurse – Theatre
 Registered Nurse – Wound Care
 Registered Nurse – other / Define:
 Social Worker – Mental Health
 Social Worker – other / Define:
 Technician – Anaesthetic
 Technician – Laboratory / Define:
 Technician – Mortuary / Define:
 Technician - Communications / Define:
 Technician – Pharmacy
 Technician – other / Define:
 Other / Define:
Professional Category – Second / Administration / Define:  DHB /  General Practice
 Allied Health / Define:
 Ambulance Paramedic / Level:
 Caregiver /  Aged Care /  Palliative Care /  DSS
 Doctor – Anaesthetist
 Doctor – General Practitioner
 Doctor – General Surgeon
 Doctor – Obstetrician
 Doctor – Orthopaedic Surgeon
 Doctor – Paediatric Surgeon
 Doctor – Plastic Surgeon
 Doctor – Other Surgeon / Define:
 Doctor – Paediatrician
 Doctor – Pathologist / Disaster Victim Identification
 Doctor – Psychiatrist
 Doctor – Public Health
 Doctor – Radiologist
 Doctor – Registrar / Define:
 Doctor – RMO / House Officer / Define:
 Emergency Manager
 Emergency Management Logistician
 Enrolled Nurse / Define Speciality
 Midwife /  LMC /  Hospital
 Pharmacist
 Psychologist
 Public Health /  HPO / MOoH /  Other –define:
 Radiographer
 Registered Nurse – District / Community
 Registered Nurse – ED / Emergency Care
 Registered Nurse – Flight Nurse
 Registered Nurse – General Practice Nursing
 Registered Nurse – General Medical
 Registered Nurse – General Surgical
 Registered Nurse – ICU
 Registered Nurse – Mental Health
 Registered Nurse – Orthopaedic
 Registered Nurse – Paediatric
 Registered Nurse – Public Health
 Registered Nurse – Theatre
 Registered Nurse – Wound Care
 Registered Nurse – other / Define:
 Social Worker – Mental Health
 Social Worker – other / Define:
 Technician – Anaesthetic
 Technician – Laboratory / Define:
 Technician – Mortuary / Define:
 Technician - Communications / Define:
 Technician – Pharmacy
 Technician – other / Define:
 Other / Define:
Professional Category – Third / Administration / Define:  DHB /  General Practice
 Allied Health / Define:
 Ambulance Paramedic / Level:
 Caregiver /  Aged Care /  Palliative Care /  DSS
 Doctor – Anaesthetist
 Doctor – General Practitioner
 Doctor – General Surgeon
 Doctor – Obstetrician
 Doctor – Orthopaedic Surgeon
 Doctor – Paediatric Surgeon
 Doctor – Plastic Surgeon
 Doctor – Other Surgeon / Define:
 Doctor – Paediatrician
 Doctor – Pathologist / Disaster Victim Identification
 Doctor – Psychiatrist
 Doctor – Public Health
 Doctor – Radiologist
 Doctor – Registrar / Define:
 Doctor – RMO / House Officer / Define:
 Emergency Manager
 Emergency Management Logistician
 Enrolled Nurse / Define Speciality
 Midwife /  LMC /  Hospital
 Pharmacist
 Psychologist
 Public Health /  HPO / MOoH /  Other –define:
 Radiographer
 Registered Nurse – District / Community
 Registered Nurse – ED / Emergency Care
 Registered Nurse – Flight Nurse
 Registered Nurse – General Practice Nursing
 Registered Nurse – General Medical
 Registered Nurse – General Surgical
 Registered Nurse – ICU
 Registered Nurse – Mental Health
 Registered Nurse – Orthopaedic
 Registered Nurse – Paediatric
 Registered Nurse – Public Health
 Registered Nurse – Theatre
 Registered Nurse – Wound Care
 Registered Nurse – other / Define:
 Social Worker – Mental Health
 Social Worker – other / Define:
 Technician – Anaesthetic
 Technician – Laboratory / Define:
 Technician – Mortuary / Define:
 Technician - Communications / Define:
 Technician – Pharmacy
 Technician – other / Define:
 Other / Define:
Post Graduate Qualifications
REGULATORY DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Regulatory Authority Number –Professional Category – Main * / Current Practicing Certificate / License /  Yes /  No /  N/A
NZMAC / Expiry Date: (day/month/year)
NZNC / Expiry Date: (day/month/year)
Attach copy of regulatory papers * / HPI / Expiry Date: (day/month/year)
Other: Define / Expiry Date: (day/month/year)
Regulatory Authority Number –Professional Category – Second * / Current Practicing Certificate / License /  Yes /  No /  N/A
NZMAC / Expiry Date: (day/month/year)
NZNC / Expiry Date: (day/month/year)
Attach copy of regulatory papers * / HPI / Expiry Date: (day/month/year)
Other: Define / Expiry Date: (day/month/year)
Regulatory Authority Number –Professional Category – Third * / Current Practicing Certificate / License /  Yes /  No /  N/A
NZMAC / Expiry Date: (day/month/year)
NZNC / Expiry Date: (day/month/year)
Attach copy of regulatory papers * / HPI / Expiry Date: (day/month/year)
Other: Define / Expiry Date: (day/month/year)
Are you a member of a professional body? /  Yes /  No
Name:
PROFESSIONAL SKILL SET DETAILS *
Indicate which module(s) you feel your skills could be used
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Evacuation Module /  Retrieval doctor
 RN – Flight nurse
 Retrieval paramedic
Are you experienced with paediatrics?
 Yes No
Acute Operative Module /  General Surgeon
 Orthopaedic Surgeon
 Anaesthetist
 RN – Theatre nurse
 Anaesthetic technician
Burns Module /  Plastic Surgeon with burns experience
 Anaesthetist
 RN – with burns experience
Are you experienced with paediatrics?
 Yes No
Public Health Module /  Public Health Physician
 Environmental Health Officer
 Public Health Officer
 RN – with public health, communicable disease, GP, immunisation programme experience
Emergency Care Module /  Adult Emergency Specialist Physicians (FACEM)
 RN – with ED experience
Women’s Health Module /  Obstetrician
 Midwife
Paediatric Emergency Care Module /  Paediatric Emergency Specialists Physician
 RN – with paediatric ED experience
Paediatric Surgical Module /  Paediatric Surgeon
 Anaesthetist
 RN – Theatre nurse with paediatric experience
 Anaesthetic technician with paediatric experience
Specialist Medical Module /  Specialist Physician with respiratory / infectious diseases experience
Plastics / Wound Care Module /  Plastic Surgeon
 RN – with plastics / wound experience
Mental Health Module /  Psychiatrist
 Psychologist
 RN – with mental health experience
Primary Care Module /  Primary Care Physician
 RN – with primary care experience
Inpatient Care Module /  RN – with medical / surgical experience
Are you experienced with paediatrics?
 Yes No
Pharmacy Module /  Pharmacist
 Pharmacy Technician
Radiology Module /  Radiographer with plain film experience
 Radiographer with ultrasound experience
Pathology Module /  Pathology scientist
Physiotherapy Module /  Physiotherapist – with respiratory experience
Paramedic Module /  Intensive Care Paramedic
 Paramedic
Skill Competencies / Wound Care Management /  Yes /  No
Burns Care Management /  Yes /  No
Adult IV Cannulation and Phlebotomy /  Yes /  No
Paediatric IV Cannulation and Phlebotomy /  Yes /  No
Advanced Cardiac Life Support (ACLS) /  Yes /  No
Advance Cardiac Resus Course (ACRC) /  Yes /  No
Medication Certification /  Yes /  No
Please list other relevant skills:
LANGUAGE SKILL SET DETAILS *
Indicate languages in which you can converse in
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Language 1 – other than English / Name:
Language 1 – Please state and indicate level of competency / Speaking /  Native
 Good
 Fair
 Basic
Understanding /  Native
 Good
 Fair
 Basic
Reading /  Native
 Good
 Fair
 Basic
Writing /  Native
 Good
 Fair
 Basic
Language 2 – other than English / Name:
Language 2 – Please state and indicate level of competency / Speaking /  Native
 Good
 Fair
 Basic
Understanding /  Native
 Good
 Fair
 Basic
Reading /  Native
 Good
 Fair
 Basic
Writing /  Native
 Good
 Fair
 Basic
Language 3 – other than English / Name:
Language 3 – Please state and indicate level of competency / Speaking /  Native
 Good
 Fair
 Basic
Understanding /  Native
 Good
 Fair
 Basic
Reading /  Native
 Good
 Fair
 Basic
Writing /  Native
 Good
 Fair
 Basic
DRIVER LICENCE DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Current NZ Driver Licence * /  Yes /  No
Driver Licence Number *
Driver Licence Type * /  Learners /  Restricted /  Full
Driver License Expiry Date * / (Day/month/year)
Driver License Classes * /  Class 1 – Car License
 Class 2 – Medium rigid vehicle
 Class 3 – Medium combination
 Class 4 – Heavy rigid
 Class 5 – Heavy combination
 Class 6 – Motorcycle
 F – Forklift endorsement
 R – Roller endorsement
 T – Tracks endorsement
 W – Wheel endorsement
Attach copy of drivers licence *
RELEVANT EXPERIENCE DETAILS
Indicate languages in which you can converse in
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Previous Work Experience in Developing Countries / Areas * /  Yes /  No
If yes – where did you work? /  Pacific
 Asia
 Africa
 Other / Define:
Previous Work Experience in Developing Countries / Areas Details *
NB: Include what you did while there and length of stay
Previous Emergency Management or Disaster Relief Training * /  Yes /  No
What training have you received? (e.g. CIMS2, CIMS4 or Dip Emergency Management)
Previous Deployment Disaster Relief Experience * /  Yes /  No
Previous Deployment Disaster Relief Experience Details *
NB: Include location, what you did while there and length of stay
Are you a current active member of anther front line health disaster emergency response organisation, or any other organisation’s response team? /  Yes /  No
Current active member front line team details:
NB: Include name of organisation and what role you play as a member of this organisation
CITIZENSHIP DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Are you a NZ Citizen * /  Yes /  No
If you ARE NOT a NZ Citizen what is your citizenship *
Are you currently legally able to work in NZ * /  Yes /  No
NZ Passport Number *
NZ Passport Expiry Date * / (Day/month/year)
NZ Passport Full Name *
NZ Passport Place of Issue *
Other Citizenship Passport Number *
Other Citizenship Passport Expiry Date * / (Day/month/year)
Other Citizenship Passport Full Name *
Other Citizenship Passport Place of Issue *
Do you have a visa associated with your passport? * /  Yes /  No
What is the visa for? *
Expiry Date of Visa * / (Day/month/year)
Attach copy of passport photo page(s) and visa page(s) *
MEDICAL / VACCINATION DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Level of Fitness * /  No exercise
 Exercise at least 30 minutes a day two times a week
 Exercise at least 30 minutes a day between three and five times a week
 Exercise at least 30 minutes a day more than 5 times a week
Current Vaccinations and date immunised * /  Diphtheria / Date: (Day/month/year)
 Tetanus / Date: (Day/month/year)
 Pertussis (Whooping Cough) / Date: (Day/month/year)
 Measles / Mumps / Rubella / Date: (Day/month/year)
 Hepatitis A / Date: (Day/month/year)
 Hepatitis B / Date: (Day/month/year)
 Influenza / Date: (Day/month/year)
 Typhoid / Date: (Day/month/year)
 Poliomyelitis / Date: (Day/month/year)
 Meningococcal C / Date: (Day/month/year)
 Meningococcal ACWY / Date: (Day/month/year)
 Tuberculosis / Date: (Day/month/year)
Extended Vaccinations /  Cholera / Date: (Day/month/year)
 Rabies / Date: (Day/month/year)
 Japanese Encephalitis / Date: (Day/month/year)
Attach copy of vaccination passport / documentation *
Do you currently have any medical conditions that could affect your ability to function effectively as a team member during a response? * /  Yes /  No
If yes – please specify *
Do you have any allergies? * /  Yes /  No
If yes – please give details *
Do you have any phobia? * /  Yes /  No
If yes – please give details *
DEPLOYMENT DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Availability for Deployment Within NZ * /  Available immediately – less than 24 hours notice required
 Between 24 and 72 hours notice required (1 – 3 days)
 At least 72 hours noticed required (more than 3 days)
 Not available for domestic deployment
Availability for Overseas Deployment * /  Available immediately – less than 24 hours notice required
 Between 24 and 72 hours notice required (1 – 3 days)
 At least 72 hours noticed required (more than 3 days)
 Not available for overseas deployment
REFERENCE DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Reference Details # 1 – Current Manager * / Title
First Name
Surname
Mobile Phone Number
Alternative Phone Number
Preferred Email Address
Alternative Email Address
Your relationship to Reference
Reference Details # 2 (person who has worked with you within the last 5 years * / Title
First Name
Surname
Mobile Phone Number
Alternative Phone Number
Preferred Email Address
Alternative Email Address
Your relationship to Reference
Do you give permission for your references to be contacted? * /  Yes /  No
EMERGENCY CONTACTS DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
Emergency Contact # 1 * / Name
Relationship
Home Phone Number
Work Phone Number
Personal Mobile Number
Work Mobile Number
Home Email Address
Work Email Address
Emergency Contact # 2 * / Name
Relationship
Home Phone Number
Work Phone Number
Personal Mobile Number
Work Mobile Number
Home Email Address
Work Email Address
AGREEMENT & CONFIRMATION DETAILS
*Demotes MANDATORY field – this information must be completed if registration is to be completed
I have read and understood the Code of Conduct for NZ personnel * /  Yes /  No
Attach copy of signed NZMAT Code of Conduct *
If deployed I agree to abide by the Code of Conduct for NZ personnel * /  Yes /  No
I confirm that I have declared any current medical conditions and could affect my ability to function effectively as a team member during a deployment * /  Yes /  No
I understand that the preferred deployments will be of 7 to 14 days duration plus travel time (if required), and that deployment duration may be shortened or (by agreement) extended, and that planned deployments may be cancelled at short or no notice if requirement change * /  Yes /  No
I agree to work as a team member as directed by the NZMAT Team Leader or his/her delegate(s), and as rostered and scheduled * /  Yes /  No
I agree to comply with all directions from the NZMAT Team Leader, or his/her delegate(s), regarding personal or team security precautions or restrictions on on-work activities * /  Yes /  No
I acknowledge that my work assignments may vary during deployment, and I understand that rosters and schedules may change at short notice according to circumstances and requirements at the time * /  Yes /  No
I understand that I may work and be accommodated in damaged, austere or less than fully functioning environments * /  Yes /  No
I understand that I may be required to share accommodation with other NZMAT personnel or live in communal accommodation * /  Yes /  No
I understand that flexibility, adaptability and willingness to work in new and innovative ways are likely to be required during any deployment * /  Yes /  No
I understand that some aspects of work during a deployment may involve traumatic sights or actions * /  Yes /  No
I understand that information provided in this registration form may be shared with health professional organisations to enable the advance selection and deployment of suitable personnel for deployment(s) * /  Yes /  No
I confirm that I give permission for a criminal vetting be completed * /  Yes /  No
I confirm that I give permission for a professional vetting be completed * /  Yes /  No
I confirm that I wish to register as an NZ health volunteer * /  Yes /  No

Updated January 2015 Page 1 of 16