Disaster Preparedness - VMAT application




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Animal health > Disaster preparedness > VMAT program > Application

VMAT application

The VMATs provided veterinary emergency services for the federal government from 1993-2007. The federal government recently developed its own national veterinary response team, so now the VMATs seek to fill gaps at the state level. The AVMA VMAT program seeks volunteers to serve on teams which will offer services in the areas of early assessment, basic veterinary treatment, and training in disaster response.

Please note: This state level AVMA VMAT program is not intended to supplant current programs or systems (SART, CART, Veterinary Medical Reserve Corps etc) and VMAT members are encouraged to be members of their state response teams.

Please fill out the form below to apply to be a volunteer for the VMAT program.

Questions? Please contact Dr. Heather Case, Coordinator of Emergency Preparedness and Response at 847-925-8070 ext. 6632; hcase@avma.org

NOTE: Fields marked with an asterisk ( * ) must be completed.

Background information

AVMA Member ID number (if applicable):

* I am a: (Please choose one)


	Veterinarian
	License #:

	Graduation School:

	Graduation Year:

	Veterinary Technician

	Certified Veterinary Technician

	Certification #:

	CVT Program Completed:

	Year:

	Other (Pharmacists, Mental Health, etc.)
	Please specify:

3)	*I have prior VMAT experience: Yes No

	If yes,

	VMAT Team #:	Years on team:

4)	*Name

	First	MI	Last

5)	*Mailing Address

	Street 1:

	Street 2:

	City:	State:	Zip code:

	County:

6)	Name of Employer:

7)	Work Address

	Street 1:

	Street 2:

	City:	State:	Zip code:

	County:

8)	Phone

	*Home:	Work:

	Cell:	Fax:

9)	Email:

10)	Emergency Contact Information

	Name:


	First	MI	Last

	Relationship:		Phone number:

Experience/Skills

11)

*Please check all species that you normally treat/ handle/ have experience with:


Beef	Cervidae	Birds	Dairy

Small Animal	Exotic	Swine	Poultry

Zoo	Equine	Small Ruminant	FSIS

Other Government	Other

12)

Please check below the job related experience/skills you have with the above species:


Animal Rescue	Animal Handling/Grooming	Animal Grading/Judging

Animal Training

13)

Please check below the additional skills you have:


Management Skills	Logistical Skils	Communication Skills	Laboratory

Other relevant certifications or training

Training

14)

*Please indicate the following FEMA training courses you have completed:


IS-100	IS-200	IS-300	IS-700	IS-800	IS-402

IS-10	IS-11	IS-111

15)

Other training courses completed:


Agert	HazMat	FAD Awareness	FADD (Plum Island)	WMD

CBRN	Logistics	Safety	Admin	Comm

Other (Please list)

Additional Information

16)

*Current vaccinations*:


Rabies	Tetanus	Hepatitis A	Hepatitis B

*Vaccination information will be used by the program administrator for other purposes relating to the safety and well being of volunteers.

17)

Personal Protective Equipment (PPE):


Fit tested for respirator

Respirator type:	Date: (mm/dd/yy)

PPE trained

18)	Deployment History:

19)	*Certification
	I am aware that any omission, falsification, misstatements or misrepresentations above may disqualify me for consideration. I understand that any information I give may be investigated as allowed by law. I consent to the release of information to investigators, personnel staff and other authorized employees of the AVMA. I certify to the best of my knowledge and belief all of the statements contained herein are true, correct, and complete and made in good faith.

	I AGREE	I DISAGREE

20)	*Signature

	By typing your name you agree that this is valid as your signature.


	Printed Name	Date (mm/dd/yy)

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American Veterinary Medical Association