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Form 1045 Rev. Nov. 1941 AMERICAN RED CROSS NURSING SERVICE 66 Name in full, Smith (last) Justin (first) Catherine (middle) Tel. No. Ni4-2000 If married, give maiden name Year of birth Marital status sugle Husband's name Permanent address Keep (single, (street) married Signature widowed, divorced) 2523- (city) Breaklyn (county) n.y. (state) Probable address for the next year salue (street) (city) (county) (state) and address of nearest relative or friend in United States: Mrs Give name (name) & (relationship) 744 asbloud (address) air Buffalo ny Are you employed in nursing at the present time? Yes No PRESENT EMPLOYMENT (check below) Name of agency or institution with which employed Institutional Public health Industrial Private duty Other (write in) Government Service: Army, Regular Navy, Regular Veterans Administration Reserve Reserve Children's Bureau U.S.P.H. Service U.S. Indian Service MAJOR RESPONSIBILITIES Administration Teaching Private duty of present employment Supervision General Staff Other (specify): How many years did you attend HIGH SCHOOL? One Two Three Four Graduated Yes No SINCE GRADUATION FROM YOUR SCHOOL OF NURSING have you ever had- 1. A postgraduate course or experience in any of the following special services? Postgraduate course Experience in hospital in a hospital or public health field (at least 3 months) (at least 6 months) Communicable disease nursing (include Tbc) Psychiatric Nursing Operating room Anaesthesia Public health nursing 2. Have you taken any courses in a college or university? Less than One Two Three Four Bachelor's Master's P.H.D. Certificate in *one year year years years years degree degree degree Public Health x/2 In what major field was above study? Public Health & Hospital administration What languages, other than English, do you speak? none williate Academic year MAR 4 1942 (OVER)

Page data

Page
10
Source index
0
Type
photo
Media ID
7ce4585ddc7c5d94
Size
unknown

Document data

ID
2662273
Core
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Type
document
DTO data
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Document identity
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Document source metadata
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Document source extras
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    "naId": 2662273,
    "coverageEndDate": {
        "day": 21,
        "logicalDate": "1942-12-21",
        "month": 12,
        "year": 1942
    },
    "coverageStartDate": {
        "day": 23,
        "logicalDate": "1918-11-23",
        "month": 11,
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Page context
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    "ocrText": "Form 1045\nRev. Nov. 1941\nAMERICAN RED CROSS\nNURSING SERVICE\n66\nName in full, Smith (last) Justin (first) Catherine (middle)\nTel. No. Ni4-2000\nIf married, give maiden name\nYear of birth\nMarital status\nsugle\nHusband's name\nPermanent address Keep (single, (street) married Signature widowed, divorced) 2523- (city) Breaklyn (county) n.y. (state)\nProbable address\nfor the next year\nsalue\n(street)\n(city)\n(county)\n(state)\nand address of nearest relative or friend in United States:\nMrs Give name (name) & (relationship) 744 asbloud (address) air Buffalo ny\nAre you employed in nursing at the present time? Yes\nNo\nPRESENT EMPLOYMENT (check below) Name of agency or institution with which employed\nInstitutional\nPublic health\nIndustrial\nPrivate duty\nOther (write in)\nGovernment Service: Army, Regular\nNavy, Regular\nVeterans Administration\nReserve\nReserve\nChildren's Bureau\nU.S.P.H. Service\nU.S. Indian Service\nMAJOR RESPONSIBILITIES\nAdministration\nTeaching\nPrivate duty\nof present employment\nSupervision\nGeneral Staff\nOther (specify):\nHow many years did you attend HIGH SCHOOL? One\nTwo\nThree\nFour\nGraduated\nYes\nNo\nSINCE GRADUATION FROM YOUR SCHOOL OF NURSING\nhave you ever had-\n1. A postgraduate course or experience in any of the following special services?\nPostgraduate course\nExperience in hospital\nin a hospital\nor public health field\n(at least 3 months)\n(at least 6 months)\nCommunicable disease nursing (include Tbc)\nPsychiatric Nursing\nOperating room\nAnaesthesia\nPublic health nursing\n2. Have you taken any courses in a college or university?\nLess than\nOne\nTwo\nThree\nFour\nBachelor's\nMaster's\nP.H.D.\nCertificate in\n*one year\nyear\nyears\nyears\nyears\ndegree\ndegree\ndegree\nPublic Health\nx/2\nIn what major field was above study?\nPublic Health & Hospital administration\nWhat languages, other than English, do you speak?\nnone\nwilliate\nAcademic year\nMAR 4 1942\n(OVER)"
}