Bali Volunteers Personal Information

Can you please help us by completing this questionnaire?

We are updating a comprehensive database of all volunteers associated with the Bali Bomb crisis.

Your name is on the list.

Where we already have some information, this is shown on the form. Can you please check and correct as necessary.

Please complete the relevant sections of this survey, save it, and email the form back to Graeme Stevens at volunteer@balisos.com - Or you can fax it to: 972 248

If you have any questions you can phone to 972 248 or 0816 299 506 preferably between 9am and 5pm.

Confidentiality

The information you provide will be kept confidential and not released to other parties without your permission.

This survey has three main parts.

- Contact information

- Skills/Experience and Time to offer

- Experience during the crisis from 12^th October

Do you wish to participate in this Survey?	«SurveyYesNo»	(Yes /No) If No, thank you for returning the form with just this answer. And thank you for all your help as a volunteer.
Do you wish to be registered as a volunteer for any future emergency?	«VolunteerFuture»	(Yes /No) If No, please leave out Part 2.
Do you wish to receive information about Volunteer activities, such as social events?	«VolunteerActivities»	(Yes /No)
Have you received any counselling following your volunteer work?	«VolunteerCounselling»	(Yes /No)

PART 1 – CONTACT INFORMATION

Nama - Name	«FullName»
Hand Phone Hand Phone	«HandPhone»
Telephone Rumah Home Phone	«HomePhone»
Telephone Bisnis Business Phone	«WorkTelp»
Fax	«Fax»
Email	«EmailAddress»
Kebangsaan - Nationality	«Nationality»
Alamat - Address Street	«Address»
Banjar	«Banjar»
Kota - Town/City	«City»
Kabupaten - Regency	«Regency»
Kecamatan - Locality	«Locality»

Current Organisations

Membership of Non-Profit and Non-Government Organisations	Organisation	Position
	«Organisation1»	«OrgPosition1»
	«Organisation1»	«OrgPosition1»
	«Organisation1»	«OrgPosition1»

PART 2 – SKILLS & EXPERIENCE

Languages

Where you have a skill in language, please indicate the level of skill from1 (lowest) to 5 (highest).

Level 5 is either your native language, or would indicate an ability to translate written text into your native language.

Level 3 would indicate fluent spoken language.

Indonesia - Indonesian	«Indonesian»
Prancis - French	«French»
Spanyol - Spanish	«Spanish»
Inggris - English	«English»
Swedia - Swedish	«Swedish»
Portugal - Portugese	«Portugese»
Italia - Italian	«Italian»
Belanda - Dutch	«Dutch»
Cina - Chinese	«Chinese»
Jerman - German	«German»
Jepang - Japanese	«Japanese»
Lain - Other	«OtherLang»

Medical Skills

Please use an ‘x’ to indicate your area of knowledge and experience.

Dokter - Doctor	«Docter»
Surgeon	«Surgery»
Perawat - Nurse	«Nurse»
Anastesi - Anaesthesia	«Anaesthesia»
Para Medik - Paramedic	«Paramedic»
Medical Training	«MedicalTraining»

Healing Support

Please use an ‘x’ to indicate your area of knowledge and experience.

Apoteker - Chemist	«Chemist»
Physical Therapy	«PhysicalTherapy»
Consultan/Terapi Counselling/Therapy	«CounsellingTherapy»
Psychiatrist	«Psychiatrist»
Psikolog - Psychologist	«Pshichologist»

Administration

Secretarial	«Secretarial»
Receptionist	«RecTelAdmins»
Accounting	«Accounting»
Book Keeping	«BooKAdmins»
Engineering	«Engineering»
Cleaning Service	«CleaningService»
Security	«Security»
Logistic	«Logistics»
Teacher	«Teacher»
Operator	«Operator»
Management	«Management»
Other	«OtherNonMed1»

Computer Skills

Excel	«Excel»
Word Processing	«WordProcessing»
Data Base	«DataBase»
Graphics	«Graphics»
Internet	«Internet»
Networks	«NetworkSetUp»
Other	«OtherComp1»

Communications & Media

Web	«WebMed»
PR	«PRMed»
Writing	«WritingMed»
Editing	«EditingMed»
Media W	«MediaWMed»
Telecommunications	«Telecomonications»
Photography	«PhotoMed»

Transportation

Driver	«DriverTransp»
Car Provider	«CarProvTransp»
Bike Provider	«BikeProvTransp»

Availability

Are you available for activities that assist Indonesian families that require ongoing support?

«Availability»

Full time

Part Time

Specific Hours

Not Available

Availability Notes

«PresentInvol»

Other Notes and Comments

«AvailabilityNotes»

Thank you for completing Part 2

PART 3 – CRISIS SUPPORT HISTORY

What Hospital(s) were you involved with as a Volunteer

RSUP Sanglah	«RsupSanglah»
Darma Husada	«DharmaHusada»
Graha Asih	«GrahaAsih»
Kuta Clinic	«KutaClinic»
Bakti Rahayu	«BaktiRahayu»
Kasih Ibu	«KasihIbu»
Sos Medika	«SosMedika»
BIMC	«Bimc»
Klinik Kuta I	«KlinikKuta1»
Darma Yadnya	«DarmaYadnya»
Prima Medika	«PrimaMedika»
RSAD/Military HOSP	«RasdMilitaryHospital»
Surya Husada	«SuryaHusada»
Legian Clinic	«LegianClinic»
Puri Raharja	«PuriRaharja»
Wangaya	«Wangaya»
Sari Dharma	«SariDharma»
Jimbaran Clinic	«JimbaranClinic»
Other	«OtherHosp1»

What Area(s) were you involved as a volunteer

Sanglah Hotline Svc.	«SanglahHotlineSvc»
Crisis Centre	«CrisisCenter»
Morgue	«Morgue»
Counselling	«Counselling»
Bomb Sight	«BombSight»
Receptionist	«Receptionist»
Floater/Runner	«FloaterRunner»
Triage (Posko)	«Triage»
Food/Logistics	«Food»
Database	«DataBase1»
Ubud Hotline Svc.	«UbudHotLineSvc»
Ubud Media Centre	«UbudMediaCenter»
Other	«AreaOthers»

Physical Contact

«ContactPhysically»

Did you at any time come into contact physically with any of the victims alive or dead?

Thank you for completing this survey for us.

Please save this form, attach it to an email, and send to volunteer@balisos.com

If you know of a person who was not involved during the Bali Bomb crisis, but would like to be a volunteer for current activities and/or future emergencies, please ask them to send an email to volunteer@balisos.com to request a survey form.