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RED CROSS BADGE NUMBER
AMERICAN RED CROSS
NURSING SERVICES
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
Brouse Clara Florine
a
IF MARRIED, GIVE MAIDEN NAME
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
988 So Cassingham Rd. Columbus 9- Franklinco Ohi
F
PRESENT ADDRESS (Street, city, zone, county, state)
above
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
Row Brouse - Elma h. y
Brother
DATE OF BIRTH (Month, day, year)
Qpril 10 - 1885
Single
Married
Separated
Widowed
Divorced
5
WHAT LANGUAGES DO YOU SPEAK?
YES
NO
e
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
Buchter College
uniod Okion
Blow R
1902-1906
Ph.B.
Science
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES/
NO
REGISTERED?
Qhio
NURSES' ASSOCIATION?
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse etc.)
SERVICE (Medicine, surgery, etc.)
SeenTreas NAME HOSPITAL states nuses 2BY WHOM EMPLOYED Board
Bdd muss CITY STATE
OF OR ORGANIZATION
Stato of Bhio
Columbus
Good
HEALTH
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
VOLUNTEER SERVICE
The purpose of the following statements is to identify the nurses who can be counted upon to respond to a call
to participate in a Red Cross chapter program. Please check the "Yes" box only if you are willing and able to
serve if called on wi thin the next 12 months.
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
1. Teach home
YES
NO
Attend an instructors' training program, if offered. (Funds are available for
YES
NO
nursing classes
training home nursing instructors. See local chapter.)
2. Serve in case
YES
NO
only in home community
Attend disaster institutes, if
YES
NO
of disaster
In other communities
offered, in preparation for service
3.5 Teach nurse's
YES
NO
4.
Accept membership on chapter com-
YES
NO
5. Assist with other chapter
YES
NO
aide classes
mittee should services be needed
programs, as needed
If you have not answered "Yes" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that
YES
NO
you will be able to serve at some time .in the future? on Company
IF UNABLE TO SERVE, GIVE MAJOR REASONS.
S IGNATURE
9/19/85
DATE September B-1945
Clarer Bouse RM,
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPOLNESS IN
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE
COMMITTEE NAMED BELOW.
NURSE RECRUITMENT COMMITTEE
ATTENTION
Fill in committee name and address before sending questionnal Arrefican Cross Nursing Service
SECRETARY
Franklin County Chapter
NURSE RECRUITMENT
74 East Gay Street
COMMITTEE
Columbus 15. Ohio
78504M
FORM 1045 Rev. July 1945
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"ocrText": "RED CROSS BADGE NUMBER\nAMERICAN RED CROSS\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nBrouse Clara Florine\na\nIF MARRIED, GIVE MAIDEN NAME\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\n988 So Cassingham Rd. Columbus 9- Franklinco Ohi\nF\nPRESENT ADDRESS (Street, city, zone, county, state)\nabove\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nRow Brouse - Elma h. y\nBrother\nDATE OF BIRTH (Month, day, year)\nQpril 10 - 1885\nSingle\nMarried\nSeparated\nWidowed\nDivorced\n5\nWHAT LANGUAGES DO YOU SPEAK?\nYES\nNO\ne\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nBuchter College\nuniod Okion\nBlow R\n1902-1906\nPh.B.\nScience\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES/\nNO\nREGISTERED?\nQhio\nNURSES' ASSOCIATION?\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse etc.)\nSERVICE (Medicine, surgery, etc.)\nSeenTreas NAME HOSPITAL states nuses 2BY WHOM EMPLOYED Board\nBdd muss CITY STATE\nOF OR ORGANIZATION\nStato of Bhio\nColumbus\nGood\nHEALTH\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\nVOLUNTEER SERVICE\nThe purpose of the following statements is to identify the nurses who can be counted upon to respond to a call\nto participate in a Red Cross chapter program. Please check the \"Yes\" box only if you are willing and able to\nserve if called on wi thin the next 12 months.\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\n1. Teach home\nYES\nNO\nAttend an instructors' training program, if offered. (Funds are available for\nYES\nNO\nnursing classes\ntraining home nursing instructors. See local chapter.)\n2. Serve in case\nYES\nNO\nonly in home community\nAttend disaster institutes, if\nYES\nNO\nof disaster\nIn other communities\noffered, in preparation for service\n3.5 Teach nurse's\nYES\nNO\n4.\nAccept membership on chapter com-\nYES\nNO\n5. Assist with other chapter\nYES\nNO\naide classes\nmittee should services be needed\nprograms, as needed\nIf you have not answered \"Yes\" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that\nYES\nNO\nyou will be able to serve at some time .in the future? on Company\nIF UNABLE TO SERVE, GIVE MAJOR REASONS.\nS IGNATURE\n9/19/85\nDATE September B-1945\nClarer Bouse RM,\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPOLNESS IN\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE\nCOMMITTEE NAMED BELOW.\nNURSE RECRUITMENT COMMITTEE\nATTENTION\nFill in committee name and address before sending questionnal Arrefican Cross Nursing Service\nSECRETARY\nFranklin County Chapter\nNURSE RECRUITMENT\n74 East Gay Street\nCOMMITTEE\nColumbus 15. Ohio\n78504M\nFORM 1045 Rev. July 1945"
}