HUMANITARIAN HEALTH ROSTER APPLICATION QUESTIONS (please complete and return to recruitment@uk-med.org)

First Name(s): Surname:

HUMANITARIAN HEALTH ROSTER (please tick the role(s) that you are looking to apply for)Medical Doctor

Midwife Humanitarian Coordination

Nurse Health Promoter /

Community Engagement

Logistician (general)

Paramedic Logistician (medical)

Current employment (or most recent):

Position held: Type of contract:Self Employed

Employed Consultant

Do you have any humanitarian experience?

YES If YES, please state the approximate length of time and type(s):

< 6 mnths. 6 mnths. – 1 yr. 1 – 2 yrs.

NO 2 – 5 yrs. 5 – 10 yrs. 10 + yrs.

Emergency Development Headquarters

Have you worked in a conflict setting before?

YES If YES, please state the context:

(Country/countries and dates)NO

Do you have outbreak response experience?

YES If YES, please state the approximate length of time:

< 6 mnths. 6 mnths. – 1 yr.

1 – 2 yrs.

NO

2 – 5 yrs.

5 – 10 yrs.

10 + yrs.

What type of outbreak response activities have you undertaken in the past?

Ebola Cholera Dengue Lassa Fever Yellow Fever Measles Other State:

Would you be willing to work in a high-risk context i.e. conflict, Ebola virus etc.(this is not used as a exclusion criterion for selection)

YES If YES, please state what you would be comfortable with:

Conflict setting Ebola Virus Disease

Ebola in a conflict setting

NO Insecure

environment Disaster

prone areas Austere environment

Language Skills

English French Spanish Arabic Other: ________

Speaking

Basic Basic Basic Basic Basic Intermediate Intermediate Intermediate Intermediate Intermediate

Good Good Good Good Good Very Good Very Good Very Good Very Good Very Good

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Listening

Basic Basic Basic Basic Basic Intermediate Intermediate Intermediate Intermediate Intermediate

Good Good Good Good Good Very Good Very Good Very Good Very Good Very Good

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

WritingBasic Basic Basic Basic Basic

Intermediate Intermediate Intermediate Intermediate Intermediate

Good Good Good Good Good Very Good Very Good Very Good Very Good Very Good

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

Fluent/Mother Tongue

What is the maximum length of deployment that you can undertake to the field, at any one time? < 6 weeks 6 weeks

max 6 – 12 weeks 12 + weeks

What is your nationality? (please state all that you hold current passports for)What is your official country of domicile?

For immediate deployments, where would you need to travel from?Do you have experience of training & capacity building? YES NO If YES, please describe (in less than 100 words)

In fewer than 100 words, please explain why you want to be considered for UK-Med’s Humanitarian Health Register?

In less than 100 words for each, please give ‘real life’ examples based on your past experience demonstrating your understanding and experience in the following areas:1. Ensuring excellent health care in challenging settings (if possible, please use examples from

humanitarian settings, and include examples of leadership role) – NB if a general logistician please tell us about providing excellent logistics support instead

2. Capacity building of workers and/or health systems (especially in low resource / outbreak contexts)

3. Providing expert technical advice

Please specify the date you are available from?

For remote working:For deployment internationally:

Have you previously undertaken any (Hostile Environment Awareness Training - HEAT)

YES If YES, please state when this was:

NO

________________Thank you for time – we will review your application and be in touch soon.

Please ensure you also submit an updated CV to recruitment@uk-med.org