First Responder Form First Responder Form Please note that all responses are kept strictly confidential and will not be shared outside of Health Choice Maine’s leadership and legal team. (If you prefer to answer these questions by phone, you can do so by calling 207-200-8490.) See our Save Maine’s EMS System page to learn more about how we are using these responses. Name of the Maine EMS Organization you are (or were) associated with: * Town where the EMS Organization is based: * What was (or is) your relationship to this EMS Organization? * Part-time or full-time employee Independent contractor Volunteer Did you have an employment contract? * Yes No What position(s) did you hold with this EMS organization in 2021 and/or 2022? (Check all that apply) * Firefighter EMR EMT Advanced EMT Paramedic Ambulance Driver Other If your association with this EMS organization has ended, how did it end? My employment was terminated My volunteer or independent contractor position was terminated I quit Not applicable – I am still with this organization If your association with this EMS organization has ended, was the Covid-19 vaccine rule change a factor in your departure? * Yes No Not applicable – I am still with this organization If you are still with this EMS organization, what steps did you take to stay? * I got a medical exemption I was forced to take the Covid vaccine to keep my job I willingly got the Covid vaccine I prefer not to answer Not applicable – I have left this organization Please tell us about your experience as a first responder in 2021 and/or 2022 and how the vaccine mandate impacted your work: * Contact Information Name * Name First First Last Last Email * Phone Would you like to join our mailing list and be kept up-to-date on our efforts to end the mandate? * Yes No Is it OK for Health Choice Maine to contact you if we have further questions? * Yes No If you are human, leave this field blank. Submit
