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FORM 1045
REV. 1-2-35
THE AMERICAN RED CROSS
NATIONAL HEADQUARTERS
WASHINGTON, D. c.
D
11
15 QUESTIONNAIRES DESTRUYER
ce
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,
In order to render prompt service
Chairman or
FLORENCE M. JOHNSON
in time of disaster, enrolled Red Cross
Secretary.
Nurses should report at once to the
MANHATTAN
Secretary of the Local Committee under
Local Committee.
which they are enrolled. Do not forget
the address of the Secretary.
Name in full alice Louise Buckland (miss)
If married, give husband's name
Permanent address 7West (STREET, ETC.) thash (CITY) (COUNTY) n.n.
(STATE)/
n.y.
Probable address for the next year as above.
(STREET, ETC.)
Telephone No Grawery 5:9135
L
Call apt. M23
(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)
Father George a.Bucbland-aoldBuckland 7917Paston Ave,
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.
H.P.A. school nurse in H.S.
Are you an instructor of Red Cross classes in Home Hygiene and Care of the Sick? no
Have you ever been? no - First aid
Indicate present physical condition Good
Would you respond to an emergency call in event of epidemic, disaster, war, etc. ? yes
Badge No 2596
Current date apt. 10th-1937
u
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.
5
I
6
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"ocrText": "C\nFORM 1045\nREV. 1-2-35\nTHE AMERICAN RED CROSS\nNATIONAL HEADQUARTERS\nWASHINGTON, D. c.\nD\n11\n15 QUESTIONNAIRES DESTRUYER\nce\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,\nIn order to render prompt service\nChairman or\nFLORENCE M. JOHNSON\nin time of disaster, enrolled Red Cross\nSecretary.\nNurses should report at once to the\nMANHATTAN\nSecretary of the Local Committee under\nLocal Committee.\nwhich they are enrolled. Do not forget\nthe address of the Secretary.\nName in full alice Louise Buckland (miss)\nIf married, give husband's name\nPermanent address 7West (STREET, ETC.) thash (CITY) (COUNTY) n.n.\n(STATE)/\nn.y.\nProbable address for the next year as above.\n(STREET, ETC.)\nTelephone No Grawery 5:9135\nL\nCall apt. M23\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)\nFather George a.Bucbland-aoldBuckland 7917Paston Ave,\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.\nH.P.A. school nurse in H.S.\nAre you an instructor of Red Cross classes in Home Hygiene and Care of the Sick? no\nHave you ever been? no - First aid\nIndicate present physical condition Good\nWould you respond to an emergency call in event of epidemic, disaster, war, etc. ? yes\nBadge No 2596\nCurrent date apt. 10th-1937\nu\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.\n5\nI\n6"
}