Health and Related Professionals Survey | Survey Builder

Health and Related Professionals:

We need the help of additional qualified health professionals and related professionals to supplement our current hospital capacity temporarily as our hospitals are challenged by a surge of seriously ill coronavirus patients. While extensive clinician resources are required to care for critical patients, there is also a need for health care professionals to fill other roles in caring for less acute patients and providing support services.

If you’re available, please complete this survey regarding your experience and your qualifications.

Survey submission may be followed up in the coming weeks with an additional phone survey or direct contact from a healthcare staffing professional.

What is your professional title?

Please list specialties or certifications

Age

Are you a current practitioner

Last date of practice

Role in last practice

Are you currently licensed

License number

First Name

Last Name

Contact information

Email

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

NYS county of residence

Would you be willing to work in all regions of New York State?

Describe your interest and ability to be able to provide your services to treat patients if the need should arise in the future.

With your help, New York State is working to protect our residents and strengthen our public health system. We appreciate your commitment to the health and safety of all New Yorkers and look forward to building on our partnership.