Pharmacist Volunteer Contact Information

Questions? 410-764-4755

COMPLETE AND FAX TO MARYLAND BOARD OF PHARMACY

410-358-6207 OR 410-358-9512

Visit www.mdbop.org and click on http://www.mdbop.org/alert/volunteerform.htm and download the form.

Yes, I would be willing to volunteer my time to distribute and/or dispense prescription drugs in an emergency situation.

NAME___________________________ LICENSE # _________ EXP DATE:______________

Are you a pharmacist or a pharmacy technician? _____________________________________________

PLEASE PROVIDE THE FOLLOWING INFORMATION

Pager______________________ Cell_________________________________

GIVE US THE ONE BEST NUMBER OR EMAIL ADDRESS THAT SHOULD BE USED IN THE EVENT OF AN ACTUAL EMERGENCY.

Daytime: Nighttime:

LIST THE COUNTIES IN WHICH YOU WOULD VOLUNTEER: (Or check here if willing to serve in any area of the State [ ] ) ______________________________________________________________________________

TELL US ABOUT WHERE YOU WORK:

NAME OF EMPLOYER/STORE# ___________________________ PERMIT # ______________

ADDRESS: __________________________________________________________________________

ZIP CODE: ___________________ COUNTY: _________________________________

PHONE: _________________________ FAX: _________________________________

EMAIL (BUSINESS) : _________________________________________________________________

WHAT ARE YOUR NORMAL WORK HOURS? ___________________________________________

TELL US ABOUT WHERE YOU LIVE:

ADDRESS: __________________________________________________________________________

ZIP CODE: ___________________ COUNTY: _______________________________

PHONE: _________________________ CELL/PAGER _____________________________________

E-MAIL (HOME) : ________________________________ FAX: _____________________________

DURING WHAT HOURS MAY YOU BE CONTACTED AT HOME? ___________________________

SPECIALIZED TRAINING/CERTIFICATION IN: [ ]Anthrax [ ]Smallpox [ ]Plague [ ]Tularemia

LANGUAGE(S) YOU SPEAK? ___________________________ SIGN LANGUAGE ____________

MARYLAND BOARD OF PHARMACY VOLUNTEER CORPS

Name___________________________________________________________________

Last First Middle

License # _________________________________ (if applicable)

Authorization Statement

I, (print name) __________________________________________

· Authorize this information to be submitted to the Maryland DHMH Disaster Response Volunteer

Database and be made available for volunteer disaster response activity at state and local levels;

· Have no health conditions that prevent me from working as a disaster volunteer;

· Will not divulge any confidential information about the clients served unless required for the

provision of services, referral or follow-up;

· Understand that my request to volunteer does not guarantee that my services will be needed;

· Assume responsibility to ask my employer for work release to volunteer in the event I am called

· Understand that my time/service is volunteered and will not receive compensation to volunteer; *

· If applicable, I have a professional license or certification in good standing and will promptly advise

the Board of Pharmacy of any condition placed on my license including its voluntary return;

* If a grant is awarded and includes a budget for retroactive reimbursement, volunteer expenses

may be covered.

___________________________________________________

(Signature and Date)

How did you learn about the Maryland Board of Pharmacy Volunteer Corps? __________________________________________________________________________________

__________________________________________________________________________________

Thank you for your collaboration in this important effort.