MILU-EM Intake Form

Submission Date*

Last Name*

First Name*

Email*

WhatsApp Number*

Phone Number (if different)

If different from WhatsApp Number

Have you completed a registration with Israel's Ministry of Health since December 1, 2023?*

If you've selected "no" below, please visit https://go.gov.il/volunteersforisrael to complete your registration.

Yes

No

In what country are you currently licensed to practice medicine?*

Please select from the below options. If you are licensed in a country that is not in the list, please "write in" your response.

Select or enter value

Are you board certified in emergency medicine?*

Yes

No

How many years have you been working in emergency medicine post-residency?*

What is the name of your current workplace / hospital system?*

How would you describe your current clinical practice environment*

Check all that apply. If there is another option not included in the below list, please feel to "write in" your response.

Select or enter value

Please list any university affiliations and faculty appointments

Please describe your current or past emergency medicine leadership experience

Please describe your emergency medicine subspeciality training

Check all that apply. If there is another option not included in the below list, please feel to "write in" your response.

Select or enter value

Please provide any prior Israeli medical work experience*

Provide a brief description and duration of experience and if you have no such prior experience, please list "none"

Please provide any tactical or military medical work experience (eg military medic, military paramedic, etc.)*

Provide a brief description and duration of experience and if you have no such prior experience, please list "none"

How early can you likely be available to go to Israel for a 2 week trip?*

Please select from the below options. If there is another option not included in the below list, please feel to "write in" your response.

Select or enter value

What would be your regional or city or hospital preference(s) for placement?*

If you don't have any preference, list "any"

How much support do you have from your ED chief and/or department to participate in medical relief efforts in Israel over the coming months/years?*

1 means significant support and 7 means minimal to no support

How likely are you to be able to return to work in Israel on a voluntary basis in the coming 3 months after your initial visit (assuming all travel costs are paid for)?*

1 means very likely and 7 means very unlikely

How likely are you to be able to return to Israel to provide education and clinical support every 3-4 months over the coming 2 years once this current war is over (assuming all travel costs are paid for)?*

1 means very likely and 7 means very unlikely

Select the statement that best describes your Hebrew language skills*

Fluent including medical Hebrew

Fluent conversational Hebrew, poor medical Hebrew

Decent conversational Hebrew - I understand most spoken Hebrew but not able to speak fluently

Poor conversational Hebrew - I understand a decent amount of spoken Hebrew with poor spoken Hebrew

Minimal to none

Please list any other language skills that you may have*

If none, list "none"

Please upload your CV

Drag and drop files here or

Additional Comments or Questions

Is there anything else that you want to tell us about yourself? Please include any additional information below.

Do you have questions? Please include them here and our team will will do our best to respond in a timely manner. You can also send questions to us by email at miluem.global@gmail.com.

Send me a copy of my responses