MI REGION 6 - USAR TASK FORCE
MEDICAL SPECIALIST
Medical Specialist Information
General Description of Duties:
•The general health considerations of and delivery of medical care to all Task Force
personnel, victims and search dogs while under the supervision of the Medical Team
Manager during disaster events
•Implementing the medical action plan(s) specified by the Medical Team manager
•Accountability, maintenance and minor repairs for all issued equipment
•Performing additional tasks or duties as assigned
•
Other Task Force positions you are applying for:
1
2
3
Applicant Information
Name Last, First, Middle
Address Apt. #
City State: Michigan Zip
Home Phone
Cell Phone
Work Phone
E-mail
Address
Other
Other
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MI REGION 6 - USAR TASK FORCE
MEDICAL SPECIALIST
Sponsoring Agency / Department Information
Name
Address
City Michigan Zip
Chief -
Department
Head
Phone
Rank - Job
Classification
Employment History
Dates From - To Employer Name, Address and Phone Number
Position Specific Required Training
Yes No Be currently certified/licensed as an EMT-Paramedic, Physician Assistant,
Registered Nurse Practitioner or Registered Nurse and meet all the requirements
of the AHJ
Yes No Complete the DHS/FEMA National US&R Response System WMD Considerations
for the Medical Team course
Yes No Complete the DHS/FEMA National US&R Response System Medical Team
Training course
Yes No Trained in BTLS, ACLS and PALS regimens (or equivalent)
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MI REGION 6 - USAR TASK FORCE
MEDICAL SPECIALIST
Medical Specialist Information
Yes No Complete the DHS/FEMA National US&R Response System GPS Awareness
course
Yes No Complete all Rope Rescue Skill Sets
General Training Requirements
Yes No Critical Incident Stress Awareness training
Yes No IS-100 and IS-200 (or their equivalent) on line courses
Yes No IS-700 and IS-800B on line courses
Yes No US&R Response System Orientation
Yes No First Responder Operations Level for Hazardous Materials (OSHA
29CFR 1910.120
Yes No Certified in Cardiopulmonary Resuscitation
Yes No Respiratory Protection training per OSHA 29CFR 1910.134 (k)
Yes No DHS/FEMA National US&R Response System WMD Enhanced
Operations
Yes No Awareness Level in Confined Space Rescue per NFPA 1670
Yes No Awareness Level in Water Rescue per NFPA 1670
Yes No Awareness Level in Structural Collapse Rescue per NFPA 1670
Yes No Bloodborne Pathogen training
Operations Technician Date NFPA Operations & Technician Level Courses
Completed
Rope Rescue
Confined Space Rescue
Trench & Excavation Rescue
Structural Collapse Rescue
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MI REGION 6 - USAR TASK FORCE
MEDICAL SPECIALIST
Medical Specialist Information
Machine Rescue
Other (list)
Other (list)
US&R or Technical Rescue Incidents that lasted LESS than one operational
period (12 hours)
Date of incident Location & Name of the agency you responded with Duration
US&R or Technical Rescue Incidents that lasted MORE than one operational
period (12 hours)
Date of incident Location & Name of the agency you responded with Duration
Multiple Agency US&R Training Exercises
Date of incident Location & Name of the agency you responded with Duration
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MI REGION 6 - USAR TASK FORCE
MEDICAL SPECIALIST
Medical Specialist Information
Signatures
I certify that my answers are true and complete to the best of my knowledge.
Applicant Signature Date
Authorized Signature (Chief or Agency Head) Title
Printed/ Typed Name Date
This completed application must be attached to an e-mail
sent to the Region 6 US&R Sub-Committee at:
miregion6usar@gmail.com
AND
a printed copy (with signatures) must be mailed or
delivered to: Mt. Pleasant Fire Department, Attention Chief
Greg Walterhouse, 804 E. High St., Mt. Pleasant, MI
48855.
Questions concerning the completion of this application
can be directed to the same person.
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MI REGION 6 - USAR TASK FORCE
MEDICAL SPECIALIST
The deadline for the submission of this application is July
11, 2011. Applications received after that date may not be
accepted.
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