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FORM 1045
REV. DEC. 1939
AMERICAN RED CROSS
NATIONAL HEADQUARTERS
14 QUESTIONNAIRES
DESTRCYED
WASHINGTON, D. C.
211 "
Name in full Stinson (SURNAME) Theresh game (FIRST)
(MIDDLE)
Husband's name -
Permanent address Richmond R.R. Dutario Canada
(STREET)
(CITY)
(COUNTY)
(STATE)
Probable
for
the next address year Laurel School (CITY) Shaker Heighth (COUNTY)
Dhis
(STREET)
(STATE)
Telephone number Wash (EXCH/ANGE) Yellowstone 2340 (NO.)
Nearest relative or friend in United States, through whom you may be communicated with in
an
emergency: Mrs. Gales muchler
Cousin
(NAME)
(RELATIONSHIP)
Genesen (STREET) new York
(CITY)
(STATE)
PRESENT WORK (check below)
Name of agency or institution with which employed
Institutional Laurel school Shahes Heights This
Public Health
-
Private duty
Other (write in)
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. yes
(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?
Are you a member of the American Nurses' Association? yes-
If not, why have you allowed your membership to lapse?
Badge No. 27998
Current date 2-13-40
Name of Committee
Cleveland Shio
Note:
If a nurse does not complete and return this questionnaire, and cannot be located
within two years, her enrollment will be removed from our active files.
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"ocrText": "FORM 1045\nREV. DEC. 1939\nAMERICAN RED CROSS\nNATIONAL HEADQUARTERS\n14 QUESTIONNAIRES\nDESTRCYED\nWASHINGTON, D. C.\n211 \"\nName in full Stinson (SURNAME) Theresh game (FIRST)\n(MIDDLE)\nHusband's name -\nPermanent address Richmond R.R. Dutario Canada\n(STREET)\n(CITY)\n(COUNTY)\n(STATE)\nProbable\nfor\nthe next address year Laurel School (CITY) Shaker Heighth (COUNTY)\nDhis\n(STREET)\n(STATE)\nTelephone number Wash (EXCH/ANGE) Yellowstone 2340 (NO.)\nNearest relative or friend in United States, through whom you may be communicated with in\nan\nemergency: Mrs. Gales muchler\nCousin\n(NAME)\n(RELATIONSHIP)\nGenesen (STREET) new York\n(CITY)\n(STATE)\nPRESENT WORK (check below)\nName of agency or institution with which employed\nInstitutional Laurel school Shahes Heights This\nPublic Health\n-\nPrivate duty\nOther (write in)\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. yes\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?\nAre you a member of the American Nurses' Association? yes-\nIf not, why have you allowed your membership to lapse?\nBadge No. 27998\nCurrent date 2-13-40\nName of Committee\nCleveland Shio\nNote:\nIf a nurse does not complete and return this questionnaire, and cannot be located\nwithin two years, her enrollment will be removed from our active files."
}