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GENERAL INFORMATION
First Name:
Last Name:
Title:
LPN
MD
Medical Assistant
RN
APRN
NP
Student Nurse
Other
If other, please specify.
County of Residence:
Kauai
Hawaii
Maui
Oahu
Other
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Email:
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CLINIC INFORMATION
Affiliation:
Altres Staffing
Department of Health
-- ADULT MENTAL HLTH DIV
-- ALCOHOL/DRUG ABUSE DIV
-- COMM HEALTH DIV
-- COMMUNICABL DISEASE DV
-- COMMUNICATION OFFICE
-- DENTAL HEALTH DIV
-- DEVELOP DISABIL DIV
-- DIS OUTBREAK CNTL DIV
-- ENVIRON HLTH SVCS DV
-- ENVIRONMENTAL MGMNT DV
-- EXECUTIVE OFC ON AGING
-- FAMILY HLTH SVCS DIV
-- HAWAII DIST HLTH OFC
-- KAUAI DIST HLTH OFC
-- MAUI DIST HLTH OFC
-- STATE LABORATORIES DIV
-- TSP/HHI
-- Other
Kahu Malama Nurses
-- Medical Reserve Corps - Kauai
-- Medical Reserve Corps - Big Island
-- Maui County Health Volunteers
-- Medical Reserve Corps - Oahu
-- Military (TAMC, Naval, etc.)
-- Nursing school - Hawaii Pacific University
-- Nursing school - Kauai Community College
-- Nursing school - Maui Community College
-- Nursing school - UH Hilo
-- Nursing school - UH Manoa
-- School volunteer
-- Other
If other, please specify.
DOH Employee/Nursing School ID#:
What Is Your Role?
Clinic Manager
Registration Personnel
Vaccine Administrator
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