JOB APPLICATION Please Print Clearly and Use Black/Blue Ink Only Fax Complete Application to

Transcription

1 JOB APPLICATION Please Print Clearly and Use Black/Blue Ink Only Fax Complete Application to Available for Work First Name Middle Name Last Name Current City Zip #2 (If you have a P0 Box for your main address, please provide a non- PO Box address) City Zip Current Phone Number ( ) ( ) Other Phone Number (Cellular, Pager, Other) Type Permanent City Social Security Number Required upon employment Can you provide proof of eligibility to work in the United s? Emergency Contact (not living with you) Permanent Phone Number ( ) Zip Birth Yes No Phone / / ( ) (MM/DD/YY) Type of Profession: RN LPN Shift Preference: AM PM CNA Sitter Other Either Education Name and Location of School(s) Graduated () Type of Degree Page1 of 14

2 LICENSURE (Please list all including expired) Professional License # Expiration Has your license or certification ever been under investigation? Yes No If YES, please explain Has your license or certification ever been revoked or under suspension? If YES, please explain Yes No PROFESSIONAL CERTIFICATIONS (Please list all certifications. Ex., CCRN, RNC-NICU, QCN, CRRN) Type Expiration Resuscitation Credential Expiration Resuscitation Credential Expiration ACLS BLS EN PC RESUSCITATION CREDENTIALS Please indicate your resuscitation credential(s) by placing the expiration date next to the appropriate credential in the below table. NRP PALS TNCC CONTINUING/ PROFESSIONAL EDUCATION Course Name CEUs Earned Page 2 of 14

3 Skill Arrhythmia Interpretation Chemotherapy Administration Chemotherapy Administration Credentialed CVVN, CAVH, or CRRT Fetal Monitoring Hemodialysis Intra-Aortic Balloon Pump Intracranial Pressure Monitoring SPECIALTY SKILLS Please identify with a check v' any of the skills listed below, for which you have completed organized training or unit experience and which you have at least six months experience. Skill IV Catheter Insertion IV Conscious Sedation LVAD Mechanical Ventilation PICC Line Insertion Peritoneal Dialysis Sheath Removal Transport Skills If you have other specialty skills experience (ex., case management, infection control, other monitoring, other), please list below: Have you ever been convicted of any law violation? Include any plea of ''guilty'' or ''no contest.'' (Exclude minor traffic violations) Yes No If yes, give details (A conviction will not necessarily disqualify an applicant for employment.) Yes No Yes No Yes No Do you have any physical or mental conditions that would inhibit or restrict your ability to perform the essential functions of your job? Yes No If YES, would you be requesting any accommodations to aid you in fulfilling the essential duties of your job? Yes No If YES, what are they? ADDITIONAL INFORMATION Have you been convicted of a felony that would prohibit your employment at a health care facility? Are you currently employed? If YES, may we contact your employer? Are you a graduate from a foreign Nursing School (including Canada)? Do you have one to two years of current experience? Yes No Do you carry your own medical malpractice insurance? Yes No If yes, please list Carrier name and address and policy number. Please check all that apply: Yes No I would like to be considered for positions with NurseStat LLC where I may need to travel to an assignment. available for assignment I would like to be considered for positions where a labor dispute may exist. Page 3 of 14

4 EMPLOYMENT EXPERIENCE Please fill this information out for any job you have been employed at within the past 2 years. Please list your most recent jobs first. Make additional copies if necessary. Your Name: Social Security # : Employment s From / / (MM/DDIYY) To / / (MM/DD/YY) Full Time Part Time Yes No Supervisory experience? Yes No Was this a supplemental* assignment? Yes No Position: RN LPN CNA Other Employment s From / / (MM/DD/YY) To / / (MM/DD/YY) Full Time Part Time Yes No Supervisory experience? Yes No Was this a supplemental* assignment? Yes No Position: RN LPN/LVN CNA Other Employment s From / / (MM/DDIYY) To / / (MM/DD/YY) Full Time Part Time Yes No Supervisory experience? Yes No Was this a supplemental* assignment? Yes No Position: RN LPN CNA Other *Supplemental includes travel, per diem, and local staffing assignments. Page 4 of 14

5 EMPLOYMENT EXPERIENCE CONT'D Please fill this information out for any job you have been employed at within the past 2 years. Please list your most recent jobs first. Make additional copies if necessary. Your Name. Social Security #. Employment s From / / (MM/DD/YY) To / / (MM/DD/YY) Full Time Part Time Yes No Supervisory experience? Yes No Was this a supplemental* assignment? Yes No Position: RN LPN CNA Other Employment s From / / (MM/DD/YY) To / / (MM/DD/YY) Full Time Part Time Immediate SupeNsor Yes No Supervisory experience? Yes No Was this a supplemental* assignment? Yes No Position: RN LPN CNA Other Employment s From / / (MM/DD/YY) To / / (MM/DD/YY) Full Time Part Time Yes No Supervisory experience? Yes No Was this a supplemental* assignment? Yes No Position: RN LPN/LVN CNA Other *Supplemental includes travel, per diem, and local staffing Page 5 of 14

6 REQUEST FOR REFERENCE I authorize, from (Name of Healthcare Professional's Manager) to release information about me for the purpose of supplying a reference check. Facility Name and ) Social Security Number of Healthcare Professional: How would you rate this former employee? has applied for a nursing position with NurseStat LLC and has (Name of Healthcare Professional) given us your name as a professional reference. We would appreciate it if you would evaluate the applicant's past performance and make any additional comments you feel might assist us in making our decision in hiring this Healthcare Professional. Your comments will be kept in strict confidence. Name and Title of Reference: Phone Number Facility Name- : City, St Zip: s Healthcare Professional was employed: From Healthcare Professional's Title Clinical Area Worked To Quality of Work Productivity Professionalism Emotional Stability Flexibility Dependability Enthusiasm Leadership Ability Communication Skills Attendance/Punctuality Appearance Customer Service Skills Exceeds Meets Meets Some Does Not Meet Expectations Expectations Expectations Expectations Reason this Healthcare Professional left your facility: Comments (please continue on back, if necessary) Terminated Resigned Lay-off Temporary Would you hire this Healthcare Professional again? Yes No Please return this form to: NurseStat LLC Or fax to: Kennedy Bridge Road Harrodsburg, KY Page 11 of 14

7 REQUEST FOR REFERENCE I authorize, from (Name of Healthcare Professional's Manager) to release information about me for the purpose of supplying a reference check. Facility Name and ) Social Security Number of Healthcare Professional: How would you rate this former employee? has applied for a nursing position with NurseStat LLC and has (Name of Healthcare Professional) given us your name as a professional reference. We would appreciate it if you would evaluate the applicant's past performance and make any additional comments you feel might assist us in making our decision in hiring this Healthcare Professional. Your comments will be kept in strict confidence. Name and Title of Reference: Phone Number Facility Name- : City, St Zip: s Healthcare Professional was employed: From Healthcare Professional's Title Clinical Area Worked To Quality of Work Productivity Professionalism Emotional Stability Flexibility Dependability Enthusiasm Leadership Ability Communication Skills Attendance/Punctuality Appearance Customer Service Skills Exceeds Meets Meets Some Does Not Meet Expectations Expectations Expectations Expectations Reason this Healthcare Professional left your facility: Comments (please continue on back, if necessary) Terminated Resigned Lay-off Temporary Would you hire this Healthcare Professional again? Yes No Please return this form to: NurseStat LLC Or fax to: Kennedy Bridge Road Harrodsburg, KY Page 13 of 14