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RED CROSS BADGE NUMBER
AMERICAN RED CROSS
16187
NURSING SERVICES
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
IF MARRIED, NAME
Thousen GIVE MAIDEN and
52447
HUSBAND'S NAME
PERMANENT ADDRESS (Street, city, zone, county, state)
PRESENT ADDRESS (Street, city, zone, county, state)
4125 V. Cocof
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
DATE OF BIRTH (Month, day,
Kg Hourgen year) 237
WHAT LANGUAGES DO YOU SPEAK?
Jeer 5 1883
Single
Married
Separated
Widowed
Divorced
YES
NO
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
REGISTERED?
x
X
NURSES' ASSOCIATION?
4.
x
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse, etc.)
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
Stoff
SERVICE (Medicine, surgery, etc.)
Racroments Country
CITY Calif STATE
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 months.
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
1. Teach home
YES
NO
Attend an instructors' training program, 1f offered. (Funds are available for
YES
NO
nursing classes
training home nursing instructors. See local chapter.)
2. Serve in case
YES
NO
only in home community
Attend disaster institutes, if
YES
NO
of disaster
In other communities
offered, in preparation for service
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
agency felling
nor 26 - 1945
$ IGNATURE
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY IN
AND WILLINGNESS agency TO SERVE AND YOUR FAITHFULNESS -
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE
COMMITTEE NAMED BELOW.
ATTENTION
Fill in committee name and address before sending questionnaire to nurse.
SECRETARY
Mrs. alice heilds, Chairman
NURSE RECRUITMENT
Sacramento Calef
1300
COMMITTEE
78504M
FORM 1045 Rev. July 1945
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"ocrText": "RED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n16187\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nIF MARRIED, NAME\nThousen GIVE MAIDEN and\n52447\nHUSBAND'S NAME\nPERMANENT ADDRESS (Street, city, zone, county, state)\nPRESENT ADDRESS (Street, city, zone, county, state)\n4125 V. Cocof\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nDATE OF BIRTH (Month, day,\nKg Hourgen year) 237\nWHAT LANGUAGES DO YOU SPEAK?\nJeer 5 1883\nSingle\nMarried\nSeparated\nWidowed\nDivorced\nYES\nNO\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nREGISTERED?\nx\nX\nNURSES' ASSOCIATION?\n4.\nx\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse, etc.)\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nStoff\nSERVICE (Medicine, surgery, etc.)\nRacroments Country\nCITY Calif STATE\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 months.\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\n1. Teach home\nYES\nNO\nAttend an instructors' training program, 1f offered. (Funds are available for\nYES\nNO\nnursing classes\ntraining home nursing instructors. See local chapter.)\n2. Serve in case\nYES\nNO\nonly in home community\nAttend disaster institutes, if\nYES\nNO\nof disaster\nIn other communities\noffered, in preparation for service\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\nagency felling\nnor 26 - 1945\n$ IGNATURE\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY IN\nAND WILLINGNESS agency TO SERVE AND YOUR FAITHFULNESS -\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONNAIRE AND RETURN IT PROMPTLY TO THE\nCOMMITTEE NAMED BELOW.\nATTENTION\nFill in committee name and address before sending questionnaire to nurse.\nSECRETARY\nMrs. alice heilds, Chairman\nNURSE RECRUITMENT\nSacramento Calef\n1300\nCOMMITTEE\n78504M\nFORM 1045 Rev. July 1945"
}