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2 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

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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"
}