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29 QUESTIONNAIRE%
I
2
-
FORM 1045
AMERICAN RED CROSS
REV. DEC. 1939
NATIONAL HEADQUARTERS
I
WASHINGTON. D.C.
Name in full Sheford (SURNAME)
Cognes
mercer
(FIRST)
(MIDDLE)
5
Husband's name
1372
Permanent address Riverside (STREET) Drive (CITY) New York (COUNTY) h.4. (STATE) n.4
Probable address
for the next year 1372 Reverside for ny City N.Y
11.4
(STREET)
(CITY)
(COUNTY)
(STATE)
Telephone number Wadavori 3. .2797
(EXCHANGE)
(NO.)
Nearest relative or friend in United States, through whom you may be communicated with in
an emergency:
miss Camille Shuford
Sister
(NAME)
(RELATIONSHIP)
1372 Riveiside Revice hycing
n.y
(STREET)
(CITY)
(STATE)
PRESENT WORK (check below)
Name of agency or institution with which employed
Institutional
Public Health
Private duty
Other (write in) Technician. Vanderbill Clinic - Prealylin Hopilar Milial Centri
Government Service: Army
U.S.P.H.Service
Veterans Administration
Navy
U.S.Indian Service
Children's Bureau
IF NOT ACTIVE IN NURSING check field of nursing with which you are most familiar:
Institutional
Public Health
Private duty
Other (write in)
Would you respond to an emergency call in event of local or national emergency, such as
epidemic, flood, war, etc. If associates meded
(Granted of course that you could be released from present employment)
Present physical condition good
Would you be interested in teaching classes in Home Hygiene and Care of the Sick?
2
Are
you If a member of the American Nurses' Association? yes
not, why have you allowed your membership to lapse?
Badge No. 29668
Current date March 14.1940
Name of Committee
Note: If a nurse does not complete and return this questionnaire, and cannot be located
within two years, her enroilment will be removed from our active files.
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- Source index
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- Media ID
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Document data
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- Core
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- Type
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"ocrText": "5\n5\na\nfor\n29 QUESTIONNAIRE%\nI\n2\n-\nFORM 1045\nAMERICAN RED CROSS\nREV. DEC. 1939\nNATIONAL HEADQUARTERS\nI\nWASHINGTON. D.C.\nName in full Sheford (SURNAME)\nCognes\nmercer\n(FIRST)\n(MIDDLE)\n5\nHusband's name\n1372\nPermanent address Riverside (STREET) Drive (CITY) New York (COUNTY) h.4. (STATE) n.4\nProbable address\nfor the next year 1372 Reverside for ny City N.Y\n11.4\n(STREET)\n(CITY)\n(COUNTY)\n(STATE)\nTelephone number Wadavori 3. .2797\n(EXCHANGE)\n(NO.)\nNearest relative or friend in United States, through whom you may be communicated with in\nan emergency:\nmiss Camille Shuford\nSister\n(NAME)\n(RELATIONSHIP)\n1372 Riveiside Revice hycing\nn.y\n(STREET)\n(CITY)\n(STATE)\nPRESENT WORK (check below)\nName of agency or institution with which employed\nInstitutional\nPublic Health\nPrivate duty\nOther (write in) Technician. Vanderbill Clinic - Prealylin Hopilar Milial Centri\nGovernment Service: Army\nU.S.P.H.Service\nVeterans Administration\nNavy\nU.S.Indian Service\nChildren's Bureau\nIF NOT ACTIVE IN NURSING check field of nursing with which you are most familiar:\nInstitutional\nPublic Health\nPrivate duty\nOther (write in)\nWould you respond to an emergency call in event of local or national emergency, such as\nepidemic, flood, war, etc. If associates meded\n(Granted of course that you could be released from present employment)\nPresent physical condition good\nWould you be interested in teaching classes in Home Hygiene and Care of the Sick?\n2\nAre\nyou If a member of the American Nurses' Association? yes\nnot, why have you allowed your membership to lapse?\nBadge No. 29668\nCurrent date March 14.1940\nName of Committee\nNote: If a nurse does not complete and return this questionnaire, and cannot be located\nwithin two years, her enroilment will be removed from our active files."
}