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FORM 1045
REV. 1-2-35
a
THE AMERICAN RED CROSS
1
NATIONAL HEADQUARTERS
D
WASHINGTON, D. c.
L
to QUESTIONNAIRES DESIROYED
a
L
Dear Madam:
The National Committee on Red Cross Nursing Service requires us to submit,
er
e
annually, a report of all the Red Cross Nurses enrolled with our Committee. Will you
s
therefore, please answer the following questions and return this form to me, in the
enclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONAIRE IS FILED
a
WITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-
oganize 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.
F
IMPORTANT:
In order to render prompt service
Yours sincerely,
3
Chairman or
in time of disaster, enrolled Red Cross
Nurses should report at once to the
Jassie Granthouse
Secretary.
Secretary of the Local Committee under
which they are enrolled. Do not forget
Lexingain, Ky.
Local Committee.
the address of the Secretary.
Name in full
Laverrea Fish Harward
If married, give husband's name
Permanent address
202 church It Dublin Laureus
(STREET, ETC.)
(CITY)
(COUNTY)
georgia
(STATÉ)
Probable address for next year
705 Piermont ave apt 31 Aulaula ga
(STREET, ETC.)
Telephone No. mairs 2873
Cutauto
Fultore
(COUNTY)
Georgia
(CITY)
(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 Alice H. Bruisou 202 church It. Dublin ga. (sister)
Underline the type of work you are now doing:
Army - Navy - U.S.P.H. Service - Veterans Administration - U.S. Indian Service -
Public Health - Institutional - Private Duty - Industrial - Office Nurse - Registrar.
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
good
Would you respond emergency epidemic, disaster, war, etc. ? you
to an call in event of
W
Badge No. 38,8207
Current date
(38.010)
Apr 3-1936
8
NOTE. --If the nurse does not complete and return this questionnaire, and can not be
0
located within two years, her enrolment will be removed from our active files.
0
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"ocrText": "I\nar\nT\nL\nFORM 1045\nREV. 1-2-35\na\nTHE AMERICAN RED CROSS\n1\nNATIONAL HEADQUARTERS\nD\nWASHINGTON, D. c.\nL\nto QUESTIONNAIRES DESIROYED\na\nL\nDear Madam:\nThe National Committee on Red Cross Nursing Service requires us to submit,\ner\ne\nannually, a report of all the Red Cross Nurses enrolled with our Committee. Will you\ns\ntherefore, please answer the following questions and return this form to me, in the\nenclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONAIRE IS FILED\na\nWITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-\noganize 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.\nF\nIMPORTANT:\nIn order to render prompt service\nYours sincerely,\n3\nChairman or\nin time of disaster, enrolled Red Cross\nNurses should report at once to the\nJassie Granthouse\nSecretary.\nSecretary of the Local Committee under\nwhich they are enrolled. Do not forget\nLexingain, Ky.\nLocal Committee.\nthe address of the Secretary.\nName in full\nLaverrea Fish Harward\nIf married, give husband's name\nPermanent address\n202 church It Dublin Laureus\n(STREET, ETC.)\n(CITY)\n(COUNTY)\ngeorgia\n(STATÉ)\nProbable address for next year\n705 Piermont ave apt 31 Aulaula ga\n(STREET, ETC.)\nTelephone No. mairs 2873\nCutauto\nFultore\n(COUNTY)\nGeorgia\n(CITY)\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 Alice H. Bruisou 202 church It. Dublin ga. (sister)\nUnderline the type of work you are now doing:\nArmy - Navy - U.S.P.H. Service - Veterans Administration - U.S. Indian Service -\nPublic Health - Institutional - Private Duty - Industrial - Office Nurse - Registrar.\nAre you an instructor of Red Cross classes\nin Home Hygiene and Care of the Sick? no\nHave you ever been?\nno\nIndicate present physical condition\ngood\nWould you respond emergency epidemic, disaster, war, etc. ? you\nto an call in event of\nW\nBadge No. 38,8207\nCurrent date\n(38.010)\nApr 3-1936\n8\nNOTE. --If the nurse does not complete and return this questionnaire, and can not be\n0\nlocated within two years, her enrolment will be removed from our active files.\n0"
}