"Emergency Responder Volunteer Self-assessment Form - Peterborough City & County" - Canada

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EVR
Emergency Volunteer Registry
Emergency ● Disaster ● Pandemic
Peterborough City & County
Volunteer Self-Assessment
This form is not to be submitted to EVR! Ask these questions of yourself.
This paper will not be collected.
Emergencies, disasters, and pandemics are very demanding. If you are not in good health, not
only may you jeopardize yourself, you may further tax the already stretched resources of the
local community to respond to your health needs. It is also important to ensure that
responsibilities at home and at work are not neglected to anyone’s detriment. The following
questions are intended to help you assess your personal situation prior to volunteering to be an
Emergency Responder.
Are there any particular health hazards associated with this volunteer response (e.g. smoke and poor
air quality in large-scale fires) that would exacerbate any pre-existing health conditions? Yes
No
Are you on any medications that may make working long hours without regular sleep and/or meals
difficult? Yes
No
Is acquiring sufficient medication to take with you on this disaster assignment a problem? Yes
No
Would you have any difficulty working long hours or walking a fair distance if regular transportation is
not available? Yes
No
Would an inability to acquire tobacco and/or alcohol create a stressful situation for you? Yes
No
Have you had a recent medical check-up? Yes
No
Would your doctor disapprove of you going on a disaster assignment? Yes
No
Have you had a recent dental check-up? Yes
No
Is there any reason to suspect any dental problems may surface? Yes
No
If you want to volunteer and you are employed:
Will your employer be reluctant to allow you to take this assignment? Yes
No
Will taking this assignment jeopardize your job in any way? Yes
No
Are you in the midst of any projects that would make it difficult for you to leave your work? Yes
No
Have you recently been promoted? Yes
No
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EVR
Emergency Volunteer Registry
Emergency ● Disaster ● Pandemic
Peterborough City & County
Volunteer Self-Assessment
This form is not to be submitted to EVR! Ask these questions of yourself.
This paper will not be collected.
Emergencies, disasters, and pandemics are very demanding. If you are not in good health, not
only may you jeopardize yourself, you may further tax the already stretched resources of the
local community to respond to your health needs. It is also important to ensure that
responsibilities at home and at work are not neglected to anyone’s detriment. The following
questions are intended to help you assess your personal situation prior to volunteering to be an
Emergency Responder.
Are there any particular health hazards associated with this volunteer response (e.g. smoke and poor
air quality in large-scale fires) that would exacerbate any pre-existing health conditions? Yes
No
Are you on any medications that may make working long hours without regular sleep and/or meals
difficult? Yes
No
Is acquiring sufficient medication to take with you on this disaster assignment a problem? Yes
No
Would you have any difficulty working long hours or walking a fair distance if regular transportation is
not available? Yes
No
Would an inability to acquire tobacco and/or alcohol create a stressful situation for you? Yes
No
Have you had a recent medical check-up? Yes
No
Would your doctor disapprove of you going on a disaster assignment? Yes
No
Have you had a recent dental check-up? Yes
No
Is there any reason to suspect any dental problems may surface? Yes
No
If you want to volunteer and you are employed:
Will your employer be reluctant to allow you to take this assignment? Yes
No
Will taking this assignment jeopardize your job in any way? Yes
No
Are you in the midst of any projects that would make it difficult for you to leave your work? Yes
No
Have you recently been promoted? Yes
No
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If your employer will not pay for your time away from your job to be an Emergency Responder, will it be
financially difficult for you to do so? Yes
No
Have you talked to your colleagues about volunteering? Will volunteering create difficulties in terms of
coverage? Yes
No
Will you have to take holiday time to volunteer? If so, will this disrupt any vacation plans with your
family? Yes
No
If you are a volunteer and are not employed:
Will it be financially difficult for you to volunteer? Yes
No
Will volunteering affect your eligibility for Employment Insurance or other financial support? Yes
No
Circumstances can change—sometimes very quickly. Everyone has times when one’s life
situation is more stable than during other times. Going on an Emergency Volunteer Response
assignment is demanding enough without having to worry about what is happening at home or
leaving when things have been very stressful (either positively or negatively).
Has your life situation changed recently—for example: have you recently experienced a separation,
divorce, or a period of marital discord? Have you recently married or decided to live common-law? Has
there been a recent birth in the family? Has a family member been seriously ill and/or is anyone in your
family undergoing medical treatment? Yes
No
Have you returned recently from being away for work, volunteer work, or other assignments such as
military service? If so, are you unsure about being ready to take on a new challenge? Yes
No
Have there been any recent traumas and/or critical incidents in your life? Yes
No
Have you recently lost your job or been laid off work? Yes
No
Are there any significant financial stresses in your life? Yes
No
Have you made any important commitments (family or organizational) that would be difficult to change
and/or postpone (e.g., providing child care, caring for an elderly parent)? Yes
No
Would your family disapprove of you volunteering as an Emergency Responder? Yes
No
If you have answered “yes” to any of these questions, please seriously consider
whether volunteering to respond to a potential disaster, emergency, or pandemic is
a good choice for you. Experienced disaster responders know that before going to
help others you have an obligation to yourself and your family to ensure that you
are physically, financially, and emotionally healthy. Thank you for your serious
consideration of these matters and for your genuine concern for the well-being of
yourself, your family, and your community.
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