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3 - Attachment 4DISASTER VOLUNTEER INTAKE AND REFERRAL FORM Er: ERGEfVCY CENTEf3 ~^ CityatCampbeN '3 City of Cupertino 7 City of GBroy ^ Cily of dos AStos ^ Town c` Lo=_ Al,os Hias down of Los Gatos `^ City of Milpitas fl City of tdorfie Sereno City of Morgan L-LiR fl City of S~+lountain Jiew O Ciy of Ralo Atio fl City of.San .lose ^ City ~of $arRa Clara ^ City of Saratoga O city of .Sunnyvale ^ Gourry of Sarca Clara ^ Other PRINT PLEASE Name: First ftifidc~te lrit~ last Dare Street Address t i City State t Zip Occupation Primary Phone Cep Phone Pager E-mail Drivers License # 1 Class Please list age ' Any Physical Limitations? Are you able to Eft heavy items? {rf Under 18) _ ^ Yes ^ No If yes, up to how many pounds? Parents must accompany minor to register to volunteer If you are with a group, please specify name Availability: Please indicate when you are available. {Check all boxes that apply.) M T W Thu F Sa Su Morning Afternoon Evening Length of Time available (1 week, 1 month, open) Geographic Area: Please indicate the geographic area(s) where you can volunteer. (Choose all that apply.) ^ Central County ^ South County ^ Anywhere in County ^ North County ^ West Valley ^ Please specify if only one city Skills: Please indicate the skills you possess or tasks you are qualified/willing to do: (Choose all that apply.) Disaster Skills Office Skills Peo le Skills Manual Skills ^ CERT ' ^ Message Runner ^ Language (specify below) ^ Care 8 Shelter ^ Safety Assessment ^ Accounting ^ Child Care ^ Heavy Labor Medical: First Aid, MD, RN, EMT, NP circle) ^ Answering Phones ^ Animal Care ^ Driver (list classes below) Shelter Assistant ^ Data Entry ^ Medical ^ Carpent ~ Traffic/Crowd Control ^ General Clerical ^ Counselor ^ Plumber Radio Communications ^ Computer Systems ^ Special Populations (seniors, disabled) ^ Electrician ^ HAM Radio License ^ Interviewer/Customer Service ^ Debris Removal ~ Other (specify below) ^ Legal ^ Food Prep/Service ~.ommun¢y emergency rcesponse i earn Please list licenses, special certifications, languages or specifics indicated above: Special EquipmentNehicleslResources you can offer: Volunteer Signature (if in person): Emergency Contact and Relationship: EVC tnre~viearer. Agerx3r Contact bt32rviieaeer Corsunenis: Data Envy Date` ! f tsy: Volunteer Opportunity Referred Vii Wtnte cnl~' - Vot~txrteer Center of Silicon Valley Yepow copy - Lacaf t~rce o€ Emergen~~ Services Pink copy - Volunteer fEVC Farm Q1121]OS Attachment B ~ ~W NICE WORKER i_n„~-~=`~'' To be used in conjunction with a '-: ,, -' - c E N T E ~ Disaster Volunteer Intake and Referral Form ] City of Campbek 3 City of Cuper5no 7 City of Gilroy 3 CRy of ios At:os O town o. Los A:los Hi4=_ D Town o` Los Gates 3 City of Milpitas '] City of Monte Sereno O City of Morgan Hill City of M{n. View O City of Paio Alto City of San Joss 3 City of Sarfa Clara ] CRy o4 Saratoga D CRy of Sunnyvale ] Count' of Santa Clara D Offer PRINT PL=.45E Name: First Ilil.l. Last Date: I City 1 Jurisdiction: _. Street Address: ;City, State, Zip Code: i Driver's License Class and # OR ID #: Primary Phone: CeU /Pager: Email: Hair Color: Eye Color: Height: Are you able to lift heavy items? YES NO i tf es, u to how man ounds? J DSW Classification: l HAM Radio License !Call Sign: I In case of emergency, contact: Name ~ ;Emergency Contact Phone: Do you have any existing physical or mental limitations that would affect your ability to volunteer and where you are assigned? N_ Y_ If yes, please describe accommodations needed: Have you ever been convicted of a felony or misdemeanor? NO YES If yes, list all convictions after your t 8`" birthday, including date and nameAocation of court where convicted. (A "yes" answer is not an automatic bar to placement; a false statement will disqualify you. If yes, please explain fully. Attach a separate sheet of paper if necessary.) Volunteer Disaster Service Agreement As a City/County of Disaster Service Volunteer, I agree to perform my assignment to the best of my ability, to accept supervision for the duration of the assignment, and to observe all safety guidelines and other rules and policies of the City/County of I agree to the physical demands required for duty assigned. I understand and acknowledge that I am not an employee of the City/County of and as such, am not eligible for compensation from the CitylCounty arising from the services I am voluntarily providing. I hereby certify that the statements on this form are true and correct Depending on the nature of volunteer activities, fingerprinting and/or a background check may be required. Volunteer Signature Date TO BE COMPLETED IN THE PRESENCE OF DISASTER SERVICE WORKER OFFICIAL Disaster Service Worker Loyalty Oath or Affirmation (Govt. Code §3102) I, , do solemnly swear that I will support and defend the Constitution of the United States and the Constitution of the State of Califomia against all enemies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the Slate of Califomia; that I take [his obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties which I am about to enter. I certify under penalty of perjury that the foregoing is True and correct. DATE SIGNATURE OF DISASTER VOLUNTEER IF UNDER 18 YEARS OLD, SIGNATURE OF PARENT/GUARDIAN SIGNATURE OF OFFICIAL AUTHORIZED TO ADMINISTER LOYALTY OATH TITLE 'Far a volunteer registering for an intermittent or a single event, the expiration date is set at the discretion of the accredited Disaster Council Gut not to exceed one year. (Go•rt. Code §3102) position Assigned: DS4V Class cation: Lceation: Supervisor Assigned: Phone >g et' EVC Staff Person: Comments' Office of Emergency Services Pink copy - Voturlteer S?e Pane 2 Government Code 83 X08-&3109 Every person who, while taking and subscribing to the oath or affirmation required by this charter states as true any material matter which he knows to be false, is guilty of perjury, and is punishable by imprisonment on the state prison not less than one nor more than 14 years. Every person having taken and subscribed to the oath or affirmation required by this chapter, who, while in the employ of, or service with, the state or any county, city, city and county, state agency, public district, or disaster council or emergency organization advocates or becomes a member of any party or organization, political or otherwise, that advocates the overthrow of the government of the Unites States by force or violence or other unlawful means, is guilty of felony and is punishab?e by imprisonment in the state prison. DSW Volunteer Classifications DSW volunteers are used throughout the state to augment first responder and rescue teams in a state of war, state of emergency or a local emergency disaster, and to assist in recovery activities following a catastrophic event. The DSW volunteer classifications approved by the California Emergency Council are listed below. If an accredited Disaster Council determines it needs volunteer disaster services not included in one of these classifications, the Council may contact the Governors Office of Emergency Services, DSWVP Coordinator. Anima! Rescue, Care & Shelter Communications Community Emergency Response Team Member Finance & Administrative Staff Human Services Fire Laborer Law Enforcement Logistics Medical & Environmental Health Safety Assessment Inspector Search & Rescue Utilities _~_ =~~_ ~~ C~NTcFi PLEASE PRINT Requesting Organization Phone: Day Agency Web Contact Address ~+tY ~~P DSW Job Categories and Volunteer Position Titles {italics indicate OSW dassification) Please select one: Animal Rescue, Care 8 Shelter Laborer Animal Care ^ Animal Rescue ^ Clean-up c Construction Communications ^ Communications (HAM radio, cellular) ^ Message Runners ^ Interpreter (specify languages, induding Sign) Communify Emergency Response Team CERT Member Finance & Administrative Staff Computer ^ Data Entry a Clerical Support ^ Phones Human Services ^ Child Care ^ Counseling n Information & Referral ^ Food Service o Shelter Services ^ Interviewer Special Populations (Seniors, disabled) Volunteer Position Description (describe tasks/duties) n Heavy Equipment ^ Sandbagging n Donation Sorting/Packinglloading Law Enforcement ^ Traffic Control Assistant ~ Security Logistics ^ Driving Medical & Environmental Health ^ Health Care (circle preference: Doctor, RN, EMT or list specialty required) Safety Assessment Inspector ^ Safety Assessment Other Desired Skills/Qualifications (include language skills needed): Physical Requirements of Position: Job Site Location Is site handicapped accessible? o Yes ^ No Work site contact Work site phone How should volunteer make contact (phone site, phone office, go to site, etc.} Special instnlctions, clothing, equipment or other necessities Number of volunteers needed Minimum Houn;/Oays Needed Expected Duration ~ EVC Else Cmfy: Wolurtfeer Opport[mity Number ~ (rrformatian taketr by Darts Entry date 1~t~LUNTEER REQE~ EST FQRtltt [EYC Folrm OCiJ 200$ E1lC ~ET~uP ~r1AP EVC Manager DSW Volunteer Intake & Referral Registration gtation ;~ Station s ,~ 9 'A :~'AA+ _i l~)_ v Waiting Area (with chairs) a-~:- R~eption Station , -'° (position by Waif^g Area) ~~ 4~ ENTRANCE ~ Adapt basic design to fit any existing facility EMEf~Gc?vCY ~1%_ ___ CENSER [EVC Form 05j 2Ufl8 ppportunities Desx v These supplies are for activation of the Emergency Volunteer Center. Adapt as necessary to supplies already stocked in your jurisdiction (e.g., equipment, batteries). Basic Kit Supplies: Office Supplies ^ Clip boards (3) ^ Envelopes (125, no.10) ^ Flip chart (1, Post-it) ^ Folders (75, manila) ^ Folder labels (1 pack) ^ Index cards w/ box (200, 3x5) ^ Paper (1 pack, 3-hole, lined) ^ Paper clips and pushpins (1 variety pack) ^ Pencil erasers (3, pink) ^ Pencil sharpner (1, manual) ^ Post-it fax pads (2 pads) ^ Post-it note pads (9 pads, 3x3) ^ Rubberbands ^ Scissors (3, 8 in.) ^ Spiral notebooks (6) ^ Stapler w/ staples and remover (1 set) ^ Tape, masking (2 rolls) ^ Tape, clear (4 rolls) ^ White board (1, magnetic wl markers) ^ White board eraser (1) ^ Writing utensils O Pencils (3 dozen) O Pens (2 dozen) O Perm. markers (6, assorted colors) O Highlighter pens (6, assorted colors) EVC Plan Binder ^ Countywide Plan ^ Forms O Disaster Volunteer Intake Form O Disaster Volunteer Registration Form O Disaster Volunteer Request Form O Spontaneous Volunteer Template Plan O Position Descriptions Signs ^ EVC banner ^ EVC signs with directional arrows ^ EVC station signs Misc. Supplies: ^ County map (Thomas Guide) ^ Cameras (3, disposable) ^ First aid kit (1 kit w/ small travel pack) ^ Duct tape (2 rolls) ^ Trash bags (13-gallon) ^ Ziplock bags (gallon-size) Optional Equipment and Supplies (can be in separate kit or added to above supplies): ^ Accordian/portable file container ^ ^ Disposable, antibacterial wipes ^ ^ Emergency blankets ^ ^ Extra batteries ^ ^ Flashlights ^ ^ Lightsticks ^ ^ Paper towels ^ ^ Portable clock/radio (battery-operated) Vests, hats, shirts, badges for EVC staff Large tarp for outdoor set-up Digital camera with batteries Fax machine Laptop computer Phones (landline, cell) Copy machine Et.n~~G=~C" C F~ n: ~ i F t~ Possible questions for interviewing disaster volunteers: 1. Why have you decided to volunteer? 2. What skills do you have which may be useful as a disaster volunteer? 3. Are you prepared to possibly work in a stressful, unfamiliar situation? (If applicable) 4. Do you speak any language other than English? 5. What type of volunteer work would you like to do? 6. Do you have any special training or licenses for this type of work? (If yes, notify volunteer to be prepared to show documentation for special licenses, certification or training.) 7. Are there any physical limitations to the type of work you can do? (Can you only lift a certain amount of weight?) 8. Have you ever volunteered in a disaster situation before? 9. When, and for how long are you available to volunteer? 10. Do you prefer to work alone, with a partner, or in a group? 11. Do you have your own transportation? 12. Do you have any questions about volunteering? 13. Are you under 18? ~EYC Form 07] 2408 PRESS RELEASE ;~~, * Be sure to coordinate the release of information Public Information Officer for your jurisdiction [Insert City logo{s)] 0 to the press and the public with th Date: Time: Contact: Phone: Fax: FOR IMMEDIATE RELEASE EMERGENCY VOLUNTEER CENTER ACTIVATED Los Gatos, CA - In response to [insert name/type of incident and city/region O affected] in [insert location], the [insert city/cities], in partnership with the Santa Clar County Operational Area, have activated a local Emergency Volunteer Center in [insert city location]. The center provides a central location to mobilize and deploy volunteers to assist with the response and recovery phases of this incident. Volunteers can come to the Emergency Volunteer Center located at [insert street address and city] to register, or they may call [list area code and phone number] to learn about current volunteer needs and urgent skill requests. [IF NEEDED, ADD THIS SECTION] Volunteers with [list specific urgent skills O needed such as language, medical, etc.] are urged to contact the Emergency Volunteer Center immediately. Please contact the Emergency Volunteer Center for updated information on local volunteer opportunities as they become available EMERGENe'Y YOLUt~REER CEfWTER [EVC Form 08] 2008 Z-- '~ • ~ Z w= L W w W H W W H Z J W H N Q N O 0 0 > =~ v ~_.. LL' -~ • ~ _ J..._y ~~/~. _` VJ ~'~UR ~A~ETY tS # 1 ~5 YC?E111~~~~ ~`~ ~~~~ EM~G=tiCY :i. CEfvli ~A i . If you feel you are in danger or experiencing intolerable stress, please notify your supervisor immediately! If you are injured while volunteering, notify your supervisor or another city staff member immediately! 3. Use extreme caution when traveling to your destination. Cooperate with first responders (police, fire, etc.) during travel. ~#. If issued Volunteer ID, carry it with you at all times. ~. Be sure to follow all safety processes and procedures, including usage and storage of equipment, and keep in mind the safety of yourself and others at all times. G. If you have any physical limitations or are taking special medications that prohibit certain activities, let your supervisor know immediately! 7. Don't forget to complete your timesheet at the end of each day. 8. Never work alone! 9. If you are unsure about something, PLEASE ASK! Thank you for volunteering your time and energy to help our community! [EYC Form 10j 2008 THIS P:1GE I`TE\T101:~LL1~ LEFT BL.-~\K