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Disaster 2nd
RED CROSS BADGE NUMBER
AMERICAN RED CROSS
3770
NURSING SERVICES
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
IF
MARRIED, GIVE, MAIDEN NAME Jennie Paulence HUSBAND'S
Ind 2683
NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
PRESENT ADDRESS (Street, city, zone,
4212 N Learrilt county, state) sb Chicago 18 Its
NAME
AND ADDRESS OF NEAREST 4212 N RELATIVE OR FRIEND Learth IN THE UNITED st STATES Chicago 18 RELATIONSHIP
2015
JR. Housland day, year) BBother) 41/2nLeavills chicago 22
DATE OF BIRTH (Month,
Single
Married
Separated
Widowed
Divorced
WAXT June LANGUAGES DO 12th YOU SPEAK? 1884
YES
NO
English
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
ARE YOU CURRENTLY
YES
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
NO
REGISTERED?
x
Illinois
NURSES' ASSOCIATION?
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D. inst. staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
anesthetist
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
CITY.
STATE
Cook County Hospital
Chicago
yes
HEALTH
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
good
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
chicago YES NO Chapter American if offered. are Redcum available for YES
(tend an instructors' training program, (Funds
NO
1. Teach home
nursing classes
training home nursing instructors. See local chapter.)
YES
NO
only in home community
Attend disaster institutes, 1f
YES
NO
2. Serve in case
In other communities
offered, in preparation for service
of disaster
3. 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?
IF UNABLE TO SERVE, GIVE MAJOR REASONS
DATE
IGNATURE
Oct, AS A RED 17th CROSS NURSE 1945 DEPENDS ON YOUR ABILITY S AND pennic WILLINGNESS TO SERVE AND YOUR PAITRPOLNESS IN
YOUR VALUE
KEEPING US INFORMAD OF YOUR ADDRESS. PLEASE PILL IN THIS QUESTIONNAIRE AND RETURN If PRONPTLY TO THE
COMMITTES NAMED BELOW.
MISS JULIA- A. MooNEIL
ATTENTION
Fill in committee name and address before sending questionnaire "to nurse.
e
SECRETARY
SECRETARY
NURSE RECRUITMENT
529 so. WABASH AVE.
COMMITTEE
CHICAOO 5, ILLINOIS FORM 1045 Rev. July 1945
78504M
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"ocrText": "Disaster 2nd\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n3770\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nIF\nMARRIED, GIVE, MAIDEN NAME Jennie Paulence HUSBAND'S\nInd 2683\nNAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\nPRESENT ADDRESS (Street, city, zone,\n4212 N Learrilt county, state) sb Chicago 18 Its\nNAME\nAND ADDRESS OF NEAREST 4212 N RELATIVE OR FRIEND Learth IN THE UNITED st STATES Chicago 18 RELATIONSHIP\n2015\nJR. Housland day, year) BBother) 41/2nLeavills chicago 22\nDATE OF BIRTH (Month,\nSingle\nMarried\nSeparated\nWidowed\nDivorced\nWAXT June LANGUAGES DO 12th YOU SPEAK? 1884\nYES\nNO\nEnglish\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nARE YOU CURRENTLY\nYES\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nNO\nREGISTERED?\nx\nIllinois\nNURSES' ASSOCIATION?\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D. inst. staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nanesthetist\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nCITY.\nSTATE\nCook County Hospital\nChicago\nyes\nHEALTH\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\ngood\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\nchicago YES NO Chapter American if offered. are Redcum available for YES\n(tend an instructors' training program, (Funds\nNO\n1. Teach home\nnursing classes\ntraining home nursing instructors. See local chapter.)\nYES\nNO\nonly in home community\nAttend disaster institutes, 1f\nYES\nNO\n2. Serve in case\nIn other communities\noffered, in preparation for service\nof disaster\n3. Teach nurse's\nYES\nNO\n4. Accept 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?\nIF UNABLE TO SERVE, GIVE MAJOR REASONS\nDATE\nIGNATURE\nOct, AS A RED 17th CROSS NURSE 1945 DEPENDS ON YOUR ABILITY S AND pennic WILLINGNESS TO SERVE AND YOUR PAITRPOLNESS IN\nYOUR VALUE\nKEEPING US INFORMAD OF YOUR ADDRESS. PLEASE PILL IN THIS QUESTIONNAIRE AND RETURN If PRONPTLY TO THE\nCOMMITTES NAMED BELOW.\nMISS JULIA- A. MooNEIL\nATTENTION\nFill in committee name and address before sending questionnaire \"to nurse.\ne\nSECRETARY\nSECRETARY\nNURSE RECRUITMENT\n529 so. WABASH AVE.\nCOMMITTEE\nCHICAOO 5, ILLINOIS FORM 1045 Rev. July 1945\n78504M"
}