Public Health K-12 School Support Request
Please complete all sections and discuss directly with your health office personnel. The specific needs for your school determine the scope of work; we will deploy MRC volunteers or MCDPH staff accordingly.
School Information
School District
School Name
Street Address
City
State
Zip Code
Scheduling Information
Start Date
End Date
Shift Start Time
Shift End Time
Days of the Week Support is Needed
Monday
Tuesday
Wednesday
Thursday
Friday
Primary Contact for Staffing Requests
Pease NOTE: A copy of this information will be emailed to the address you specify below.
First Name
Last Name
Title
Phone Number
Email Address
Volunteers/Staff Information
Pease check all that apply.
Total Volunteers/Staff Needed (per day)
Specialized Skills
Data Entry – Student Information System (AZDHS, MCDPH, ASIIS)
Data Entry – School Reporting Forms (immunizations, health records)
Contact Tracing Assistance (following your established protocol)
Guardian Notification Assistance (following your established protocol)
Medically trained Assistance (triage, basic First Aid)
Vision and Hearing Testing
COVID19 Testing Assistance (preparing test kits, sending results, entering data)
OTHER (please describe)
Basic Support
School-based Testing Assistance/Support (such as vision & hearing)
Clerical Support (filing, creating records, typing, copying)
Health Assistance (checking in students under supervision of nurse/health tech)
Transmission Prevention Strategy Monitoring (masks)
OTHER (please describe)
Needed Information
Fingerprinting of Volunteers/Staff is Required
The Volunteers/Staff will Work:
--Select--
Under Direct Supervision
Independently
Please Describe Primary Activity Level (volunteers/staff will mostly be walking, sitting, standing...)
Location, Access/Entry and Parking Instructions (please be specific)
Other Notes or Comments