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Telephone number

Home phone number

Cellular phone number

Postal code

Format: G1G 1G1

Do you have your Canadian citizenship? Yes No

Are you able to communicate in French? Yes No

Are you able to communicate in English? Yes No

To which group(s) do you wish to contribute? Vaccination COVID-19 ou antigrippale (Être membre d’un ordre professionnel ou un étudiant autorisé à administrer un vaccin)
Dépistage COVID-19 (Être membre d’un ordre professionnel ou un étudiant autorisé à effectuer ou à analyser des tests de dépistage)
Enquête COVID-19 (Habiletés à réaliser des enquêtes, professionnels de la santé, policiers, etc.)
Professionnel en soins (infirmière, infirmière auxiliaires, inhalothérapeute, préposé aux bénéficiaires, etc.)
Professionnel de la santé et des services sociaux (travailleur social, éducateur, psychologue, ergothérapeute, etc.)
Personnel administratif (agent administratif, technicien en administration, etc.)
Métiers (ouvrier en maintenance, préposé en hygiène salubrité, agent de sécurité, etc)
Sans formation en santé (aide de service)

Have you obtained or are you currently studying for a diploma in the health field? Yes No

Please state its title :

If a professional license is required, is it currently valid? Yes No

What is your practice number?

In which institution do you mainly want to contribute?

If it is not possible to respond to your first choice, would you agree to work in another institution? Yes No

In which institution? Abitibi-Témiscamingue / CISSS de l'Abitibi-Témiscamingue
Bas-Saint-Laurent / CISSS du Bas-Saint-Laurent
Capitale-Nationale / CHU de Québec
Capitale-Nationale / CIUSSS de la Capitale-Nationale
Capitale-Nationale / IUCPQ - Université Laval
Chaudière-Appalaches / CISSS de Chaudière-Appalaches
Côte-Nord / CISSS de la Côte-Nord
Estrie / CIUSSS de l'Estrie - CHUS
Gaspésie - Îles-de-la-Madeleine / CISSS de la Gaspésie
Gaspésie - Îles-de-la-Madeleine / CISSS des Îles
Lanaudière / CISSS de Lanaudière
Laurentides / CISSS des Laurentides
Laval / CISSS de Laval
Mauricie-et-Centre-du-Québec / CIUSSS de la Mauricie-et-Centre-du-Québec
Montérégie / CISSS de la Montérégie-Centre
Montérégie / CISSS de la Montérégie-Est
Montérégie / CISSS de la Montérégie-Ouest
Montréal / CHU Sainte-Justine
Montréal / CHUM
Montréal / CIUSSS de l'Est-de-l'Île-de-Montréal
Montréal / CIUSSS de l'Ouest-de-l'Île-de-Montréal
Montréal / CIUSSS du Centre-Ouest-de-l'Île-de-Montréal
Montréal / CIUSSS du Centre-Sud-de-l'Île-de-Montréal
Montréal / CIUSSS du Nord-de-l'Île-de-Montréal
Montréal / CUSM
Montréal / Institut de cardiologie de Montréal
Montréal / Institut national de psychiatrie légale Philippe-Pinel
Nord-du-Québec / CRSSS de la Baie-James
Nunavik / Régie régionale de la santé et des services sociaux du Nunavik
Outaouais / CISSS de l'Outaouais
Saguenay - Lac-Saint-Jean / CIUSSS du Saguenay-Lac-Saint-Jean
Terres-Cries-de-la-Baie-James / Conseil Cri de la santé et des services sociaux de la Baie James

What are your preferred sectors? Centre de dépistage
Centre hospitalier
CLSC (Centre local de services communautaires)
CHSLD (Centre d’hébergement de soins de longue durée)
Centre de réadaptation
Centre jeunesse
Privé (ex. résidence pour aînés)

What is your availability? (Every other weekend is required for most positions in the health and social services network) Day
Evening
Night
Weekend

From what date are you available?

How many days a week are you available?

Do you agree to be in direct contact with patients who could potentially be affected by COVID-19? Yes No

During the past 14 days, have you been in the presence of someone with symptoms related to COVID-19? Yes No

Are you currently in voluntary isolation? Yes No

Are you currently in mandatory isolation? Yes No

Have you been back from your trip for less than 14 days? Yes No

Students

Medical students and residents
Students enrolled in their final year of Respiratory Therapy
Students enrolled in their third or fourth year of Midwifery
Students registered for Practical Nursing who have completed competency units 1 to 9
Students enrolled in their third or fourth year of Pharmacy
Students in the third year of the college program in pre-hospital emergency care

Professionals

Acupuncturists
Audiologists
Audioprosthetists
Chiropractors
Dentists
Denturists
Dietitians or nutritionists
Occupational therapists
Dental hygienists
Veterinary doctors
Prescription opticians
Optometrists
Speech therapists
Physiotherapists
Podiatrists
Ambulance technicians
Medical technologists
Medical electrophysiology technologists
Medical imaging technologists
Physiotherapy technologists
Dental prosthesis and appliance technologists
Pharmacists
Inhalotherapists
Midwives
Doctors
Auxiliary nurse
Candidates for the practice of nursing (CEPI)
Candidates for the practice of the profession of nursing assistant (CEPIA)
Nurses
Nursing Externs
Individuals with a medical degree from a medical school listed in the World Directory of Medical Schools