Enclosure (2) to COMDINST 6010.2B
INFORMATION QUESTIONNAIRE for
AUXILIARY HEALTH CARE PROVIDERS
This questionnaire provides information regarding your availability and ability to support CG Health
Care activities
1. Name:
2. Address:
3. Phone number:
4. Auxiliary Member Number, District, Division, Flotilla:
5. E-mail address:
6. Medical/Dental/Nursing Specialty:
7. Are you able to provide to CG Health Care Activities for at least 2 days per month during the
work-week?
8. If so, how many work-week days per month?
9. If a need existed at a CG Health Care activity during an emergency requiring deployment of CG
health care providers, would you be able to and willing to provide surge backfill medical support
(for 1-2 weeks) at the CG medical/dental clinic that you support?
Yes_____
or
No _____
10. How much time will you need in order to be able to provide surge medical support:
a. Less than one day
b. 1-3 days
c. More than 3 days but less than a week
d. Longer than 1 week
e. Generally won't be able to provide short notice, extended surge backfill support.
11. Are you comfortable with (and can you provide supporting documentation demonstrating
competency) performing routine full physical examinations (medical officers only)?
Yes_____
or
No _____
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