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FORM 1045
REV. 1-2-35
THE AMERICAN RED CROSS
D
NATIONAL HEADQUARTERS
WASHINGTON, D. c.
13 QUESTIONNAIRES DESTROYED " impulti
M
K
a
u
Dear Madam:
The National Committee on Red Cross Nursing Service requires us to submit,
annually, a report of all the Red Cross Nurses enrolled with our Committee. Will you
therefore, please answer the following questions and return this form to me, in the
enclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONNAIRE IS FILED
WITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-
ognize the value of filing this information and will return the questionnaire promptly,
as we are extremely anxious to make a very complete report to National Headquarters.
IMPORTANT:
Yours sincerely,
Chairman Secretary.
or
In order to render prompt service
in time of disaster, enrolled Red Cross
Nurses should report at once to the
DIST, QF. COLUMBIA
Local Committee.
Secretary of the Local Committee under
which they are enrolled. Do not forget
the address of the Secretary.
Name
in full a many Carter (Miss)
If married, give husband's name
Permanent address 311- south It Asaph Street alexandria, (STATE) Va
(STREET, ETC.)
(CITY)
(COUNTY)
Probable address for the next year same as above
(STREET ETC.)
Telephone No. alex-2014-28
(CITY)
(COUNTY)
(STATE)
Name and address of nearest relative or friend, in United States, through whom you may
be communicated with in an emergency. (State relationship)
Mrs. le. u Carter, (morther) 714- Queen Street, Alexandria Va
Underline the type of work you are now doing:
Army - Navy V.S.P.H. Service - Veterans Administration - U.S. Indian Service -
Public Health - Institutional - Private Duty Industrial - Office Nurse - Registrar.
Government clerk
Are you an instructor of Red Cross classes in Home Hygiene and Care of the Sick? no
Have you ever been?
no
Indicate present physical condition Fair
depend on circumstances at time of call
Would you respond to an emergency call in event of epidemic, disaster, war, etc.' ?
Badge No. 694
Current date march 1,1937
NOTE. - If the nurse does not complete and return this questionnaire, and can not be
located within two years, her enrolment will be removed from our active files.
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"ocrText": "+\nFORM 1045\nREV. 1-2-35\nTHE AMERICAN RED CROSS\nD\nNATIONAL HEADQUARTERS\nWASHINGTON, D. c.\n13 QUESTIONNAIRES DESTROYED \" impulti\nM\nK\na\nu\nDear Madam:\nThe National Committee on Red Cross Nursing Service requires us to submit,\nannually, a report of all the Red Cross Nurses enrolled with our Committee. Will you\ntherefore, please answer the following questions and return this form to me, in the\nenclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONNAIRE IS FILED\nWITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-\nognize the value of filing this information and will return the questionnaire promptly,\nas we are extremely anxious to make a very complete report to National Headquarters.\nIMPORTANT:\nYours sincerely,\nChairman Secretary.\nor\nIn order to render prompt service\nin time of disaster, enrolled Red Cross\nNurses should report at once to the\nDIST, QF. COLUMBIA\nLocal Committee.\nSecretary of the Local Committee under\nwhich they are enrolled. Do not forget\nthe address of the Secretary.\nName\nin full a many Carter (Miss)\nIf married, give husband's name\nPermanent address 311- south It Asaph Street alexandria, (STATE) Va\n(STREET, ETC.)\n(CITY)\n(COUNTY)\nProbable address for the next year same as above\n(STREET ETC.)\nTelephone No. alex-2014-28\n(CITY)\n(COUNTY)\n(STATE)\nName and address of nearest relative or friend, in United States, through whom you may\nbe communicated with in an emergency. (State relationship)\nMrs. le. u Carter, (morther) 714- Queen Street, Alexandria Va\nUnderline the type of work you are now doing:\nArmy - Navy V.S.P.H. Service - Veterans Administration - U.S. Indian Service -\nPublic Health - Institutional - Private Duty Industrial - Office Nurse - Registrar.\nGovernment clerk\nAre you an instructor of Red Cross classes in Home Hygiene and Care of the Sick? no\nHave you ever been?\nno\nIndicate present physical condition Fair\ndepend on circumstances at time of call\nWould you respond to an emergency call in event of epidemic, disaster, war, etc.' ?\nBadge No. 694\nCurrent date march 1,1937\nNOTE. - If the nurse does not complete and return this questionnaire, and can not be\nlocated within two years, her enrolment will be removed from our active files."
}