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RED CROSS BADGE NUMBER
AMERICAN RED CROSS
17721
NURSING SERVICES
MILITARY SERIAL NUMBER
World Way / Base Hosp. #45
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
Carothers Dora C
IF MARRIED, GIVE MAIDEN NAME
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
9FD#1 Coolvirre, athens, Ohio,
PRESENT ADDRESS (Street, city, zone, county, state)
AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
NAME Ins alfredERogers day, year) RFD#1, Coolville Olio
Sister
DATE OF BIRTH (Morth,
Single 4
Married
Separated
Widowed
Divorced
July 27 - 1882
YES
NO
WHAT LANGUAGES DO YOU SPEAK?
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
YES
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
ARE YOU CURRENTLY
NO
REGISTERED IN (State)
REGISTERED?
K
Ohio
NURSES' ASSOCIATION?
L
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
CITY
STATE
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
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 within the next 12 sonths.
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
1. Teach home
Attend an instructors' training program, if offered. (Funds are available for
YES
NO
YES
NO
nursing classes
training home nursing instructors. See local chapter.)
Attend disaster institutes, if
YES
NO
2. Serve in case
YES
NO
only in home community
of disaster
In other communities
offered, in preparation for service
YES
NO
4. Accept membership on chapter com-
YES
NO
5. Assist with other chapter
YES
NO
3. Teach nurse's
aide classes
mi Ittee 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?
IF UNABLE TO SERVE, GIVE MAJOR REASONS
DATE
aga-nutezed S IGNATURE and deaf
Dec. 12-1943 -
Dna C carothers.
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR PAITHPOLNESS
IN
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN If PROMPTLY TO the
COMMITTEE NAMED BELOW.
Nurse
Recruitment
c
ATTENTION
Fill in committee name and address before 109 unest iornaire to nurse.
SECRETARY
American Red Cross
1/29/46
NURSE RECRUITMENT
COMMITTEE
Jackson, Mississipp
FORM 1045 Rev. July 1945
504M
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"ocrText": "+\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n17721\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nWorld Way / Base Hosp. #45\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nCarothers Dora C\nIF MARRIED, GIVE MAIDEN NAME\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\n9FD#1 Coolvirre, athens, Ohio,\nPRESENT ADDRESS (Street, city, zone, county, state)\nAND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nNAME Ins alfredERogers day, year) RFD#1, Coolville Olio\nSister\nDATE OF BIRTH (Morth,\nSingle 4\nMarried\nSeparated\nWidowed\nDivorced\nJuly 27 - 1882\nYES\nNO\nWHAT LANGUAGES DO YOU SPEAK?\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nYES\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nARE YOU CURRENTLY\nNO\nREGISTERED IN (State)\nREGISTERED?\nK\nOhio\nNURSES' ASSOCIATION?\nL\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nCITY\nSTATE\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\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 within the next 12 sonths.\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\n1. Teach home\nAttend an instructors' training program, if offered. (Funds are available for\nYES\nNO\nYES\nNO\nnursing classes\ntraining home nursing instructors. See local chapter.)\nAttend disaster institutes, if\nYES\nNO\n2. Serve in case\nYES\nNO\nonly in home community\nof disaster\nIn other communities\noffered, in preparation for service\nYES\nNO\n4. Accept membership on chapter com-\nYES\nNO\n5. Assist with other chapter\nYES\nNO\n3. Teach nurse's\naide classes\nmi Ittee 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?\nIF UNABLE TO SERVE, GIVE MAJOR REASONS\nDATE\naga-nutezed S IGNATURE and deaf\nDec. 12-1943 -\nDna C carothers.\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR PAITHPOLNESS\nIN\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN If PROMPTLY TO the\nCOMMITTEE NAMED BELOW.\nNurse\nRecruitment\nc\nATTENTION\nFill in committee name and address before 109 unest iornaire to nurse.\nSECRETARY\nAmerican Red Cross\n1/29/46\nNURSE RECRUITMENT\nCOMMITTEE\nJackson, Mississipp\nFORM 1045 Rev. July 1945\n504M"
}