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FORM 1045
REV. 4-4-38
THE AMERICAN RED CROSS
NATIONAL HEADQUARTERS
WASHINGTON, D. c.
MAR 271959
17
QUESTIONNAIRES DESTROYED
211
Dear Red Cross Nurse:
The National Committee on Red Cross Nursing Service requires us to submit,
annually, a report of all the Red Cross Nurses enrolled with our Committee. Will you
therefore, please answer the following questions and return this form to me, in the
enclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONNAIRE IS FILED
WITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-
ognize the value of filing this information and will return the questionnaire promptly,
as we are extremely anxious to make a very complete report to National Headquarters.
IMPORTANT:
Yours sincerely,
In order to render prompt service
in time of disaster, enrolled Red Cross
THELMA M. GAGE
Chairman or
473 WESTERN-AVENUE
Secretary.
Nurses should report at once to the
Secretary of the Local Committee under
ALBANY, NEW YORK
Local Committee.
which they are enrolled. Do not forget
the address of the Secretary.
Name in full
marguente K. Jacobeen
If married, give husband's name
Permanent address
152 (STREET, Washington ETC.) ave, (CITY) albany (COUNTY) albany (STATE) ny
Probable address for the next year
same as above
(STREET, ETC.)
Telephone No.
52405
(CITY)
(COUNTY)
(STATE)
Name and address of nearest relative or friend, in United States, through whom you may
be communicated with in an emergency. (State relationship)
Underline the type of you are now
mrs J Jacobeen work (mother) 27 doing: chestnut st girard Pa
Army - Navy - U.S.P.H. Service - Veterans Administration - U.S. Indian Service -
Public Health - Institutional - Private Duty - Industrial - Office Nurse - Registrar.
Are you an instructor of Red Cross classes in Home. Hygiene and Care of the Sick? no
Organization work for state muses association
Have you ever been?
yes
Would you like to teach Red Cross classes? not at present
Indicate present physical condition
Good
Would you respond to an emergency call in event of epidemic, disaster, war, etc.? yes
Badge No. 21314
Current date
man 28,1939
NOTE. -If the nurse does not complete and return this questionnaire, and can not be
located within two years, her enrolment will be removed from our active files.
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"ocrText": "FORM 1045\nREV. 4-4-38\nTHE AMERICAN RED CROSS\nNATIONAL HEADQUARTERS\nWASHINGTON, D. c.\nMAR 271959\n17\nQUESTIONNAIRES DESTROYED\n211\nDear Red Cross Nurse:\nThe National Committee on Red Cross Nursing Service requires us to submit,\nannually, a report of all the Red Cross Nurses enrolled with our Committee. Will you\ntherefore, please answer the following questions and return this form to me, in the\nenclosed envelope, at the earliest possible date? THIS ANNUAL QUESTIONNAIRE IS FILED\nWITH YOUR RECORDS AT NATIONAL HEADQUARTERS IN WASHINGTON, D. C. We hope you will rec-\nognize the value of filing this information and will return the questionnaire promptly,\nas we are extremely anxious to make a very complete report to National Headquarters.\nIMPORTANT:\nYours sincerely,\nIn order to render prompt service\nin time of disaster, enrolled Red Cross\nTHELMA M. GAGE\nChairman or\n473 WESTERN-AVENUE\nSecretary.\nNurses should report at once to the\nSecretary of the Local Committee under\nALBANY, NEW YORK\nLocal Committee.\nwhich they are enrolled. Do not forget\nthe address of the Secretary.\nName in full\nmarguente K. Jacobeen\nIf married, give husband's name\nPermanent address\n152 (STREET, Washington ETC.) ave, (CITY) albany (COUNTY) albany (STATE) ny\nProbable address for the next year\nsame as above\n(STREET, ETC.)\nTelephone No.\n52405\n(CITY)\n(COUNTY)\n(STATE)\nName and address of nearest relative or friend, in United States, through whom you may\nbe communicated with in an emergency. (State relationship)\nUnderline the type of you are now\nmrs J Jacobeen work (mother) 27 doing: chestnut st girard Pa\nArmy - Navy - U.S.P.H. Service - Veterans Administration - U.S. Indian Service -\nPublic Health - Institutional - Private Duty - Industrial - Office Nurse - Registrar.\nAre you an instructor of Red Cross classes in Home. Hygiene and Care of the Sick? no\nOrganization work for state muses association\nHave you ever been?\nyes\nWould you like to teach Red Cross classes? not at present\nIndicate present physical condition\nGood\nWould you respond to an emergency call in event of epidemic, disaster, war, etc.? yes\nBadge No. 21314\nCurrent date\nman 28,1939\nNOTE. -If the nurse does not complete and return this questionnaire, and can not be\nlocated within two years, her enrolment will be removed from our active files."
}