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RED CROSS BADGE NUMBER
AMERICAN RED CROSS
2963
NURSING SERVICES
MILITARY SERIAL NUMBER
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHANGED
NAME (Last, first, middle)
TELEPHONE NO.
San deford anim P.
wat 6182
IF MARRIED, GIVE/MAIDEN NAME
HUSBAND'S NAME
PERMANENT zone, state)
center ADDRESS (Street, city, annie county, R.
lleven m. Saudified
148 Winsor ave., watertown 72 man. widdlesey
PRESENT ADDRESS (Street, city, zone, county, state)
same
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELATIONSHIP
leven m Sandefard
Husband
DATE OF BIRTH (Month, day, year)
June 20 1881
Single
Married
Separated
Widowed
Divorced
WHAT LANGUAGES DO YOU SPEAK?
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?
Rhode Island
NURSES' ASSOCIATION?
x
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
med. Social Worker
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
CITY
STATE
Commonwealth IF NATURE of Wassachurth
Boston
was
HEALTH
Good
OTHER THAN GOOD, SPECIFY 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, if 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?
X
IF UNABLE TO SERVE, GIVE MAJOR REASONS
full time SIGNATURE employment
DATE Sept. 30 1945
amile Q Sandiferd
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHFULNESS IN
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
NURSE RECRUITMENT STATION
NURSE RECRUITMENT
575 Boylston Street, Boston 16, Mass.
10/10/45
COMMITTEE
78504M
FORM 1045 Rev. July 1945
Page data
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- Type
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Document data
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DTO data
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Context sent to Scholar
Document identity
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"ocrText": "2\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n2963\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHANGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nSan deford anim P.\nwat 6182\nIF MARRIED, GIVE/MAIDEN NAME\nHUSBAND'S NAME\nPERMANENT zone, state)\ncenter ADDRESS (Street, city, annie county, R.\nlleven m. Saudified\n148 Winsor ave., watertown 72 man. widdlesey\nPRESENT ADDRESS (Street, city, zone, county, state)\nsame\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELATIONSHIP\nleven m Sandefard\nHusband\nDATE OF BIRTH (Month, day, year)\nJune 20 1881\nSingle\nMarried\nSeparated\nWidowed\nDivorced\nWHAT LANGUAGES DO YOU SPEAK?\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?\nRhode Island\nNURSES' ASSOCIATION?\nx\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nmed. Social Worker\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nCITY\nSTATE\nCommonwealth IF NATURE of Wassachurth\nBoston\nwas\nHEALTH\nGood\nOTHER THAN GOOD, SPECIFY 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, if offered. (Funds are available for\nYES\nNO\nnursing classes\ntraining home nursing instructors. See local chapter.)\n2.\nServe 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?\nX\nIF UNABLE TO SERVE, GIVE MAJOR REASONS\nfull time SIGNATURE employment\nDATE Sept. 30 1945\namile Q Sandiferd\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHFULNESS IN\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\nNURSE RECRUITMENT STATION\nNURSE RECRUITMENT\n575 Boylston Street, Boston 16, Mass.\n10/10/45\nCOMMITTEE\n78504M\nFORM 1045 Rev. July 1945"
}