EXCEL STAFFING SERVICES, INC. PO Box Greensboro, NC Tel: Fax: (336)

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1 EXCEL STAFFING SERVICES, INC. PO Box Greensboro, NC Tel: Fax: (336) DOH: ORIENTATION: TB DATE: EMPLOYEE SERVICE APPLICATION: CNA LPN RN (circle one) NAME TAX ID/SS# - - ADDRESS PHONE - - CITY PHONE - - STATE ZIP PHONE - - DATE OF BIRTH ARE YOU A US CITIZEN? YES NO HAVE YOU EVER BEEN AN EMPLOYEE WITH US? YES NO IF YES, WHAT DATES? WHICH STATE(S)? PROFESSIONAL INFORMATION: STATE(S) WHERE LICENSED LICENSE # CPR CERTIFICATION? YES NO EXPIRATION DATE OTHER MEDICAL CERTIFICATION EDUCATION: HIGH SCHOOL/GED DATE GRADUATED COLLEGE/TECH SCHOOL DATE GRADUATED AVAILABILITY: SHIFT PREFERENCE 1 ST 2 ND 3 RD 12 HOURS? YES NO EMPLOYMENT HISTORY: MUST BE FILLED OUT COMPLETELY COMPANY NAME PHONE - - ADDRESS CITY STATE ZIP JOB TITLE SUPERVISOR REASON FOR LEAVING COMPANY NAME PHONE - - ADDRESS CITY STATE ZIP JOB TITLE SUPERVISOR REASON FOR LEAVING COMPANY NAME PHONE - - ADDRESS CITY STATE ZIP JOB TITLE SUPERVISOR REASON FOR LEAVING The information on this application is accurate and subject to verification. I understand that any misleading or incorrect statements may render this application void. Special needs, shift variances, travel and other requirements determine what I will invoice Excel (per time slip/invoice) at a negotiated shift rate. SIGNATURE DATE

2 CLINICAL SKILLS CHECKLIST FOR RN s & LPN s NAME DATE PLEASE PUT A NUMBER INDICATING YOUR LEVELOF EXPERIENCE IN EACH AREA: 1. No experience or in need of complete supervision 2. Limited experience need moderate supervision 3. Experienced no supervision needed 4. Proficient capable of teaching and supervising CARDIAC 1. Obtaining 12 lead EKG 2. Interpreting 12 lead EKG 3. Arrhythmia Interpretation 4. Assisting with Cardio version 5. Defibrillation 6. Arrest/Resuscitation Management 7. Interpreting Heart sounds 8. Care, maintenance and monitoring of Swan Ganz Catherters 9. Care of Post Open Heart Surgery Patients 10. Care and monitoring of Balloon Pump Patients 11. Assist and care of Temporary Pacemaker Recipients 12. Titration of Medications: Dopamine Dobutrex Isuprel Levophed Digitalis Lidocaine Bretyllium Epinephrine Nipride 13. Setup and assist for Swan Ganz Catheter Insertion 14. Setup and assist for Arterial Line Catheter Insertion 15. Care of patient in shock 16. Care of patient with Fresh or Extending MI RESPIRATORY 1. Endotracheal intubation 2. Endotracheal extubation 3. Care/maintenance of Tracheal Tubes 4. Care of Ventilator Patients 5. Care of patients Weaning from Ventilator 6. Care of patients with Pulmonary Edema 7. Care of patients with Adult Respiratory Distress Syndrome (ARDS) 8. Suctioning of Tracheal and Endotracheal Tubes 9. Chest Tube Insertions 10. Care of patients with chest tubes 11. Drawing ABG s 12. Interpreting ABG s

3 CLINICAL SKILLS CHECKLIST FOR RN s & LPN s (continued) NEURO 1. Neuro Vital Signs 2. ICP Monitors 3. Care and assessment of Fresh CVA Patients 4. Care of patients with Closed Head Injuries 5. Post Op care of patient with Craniotomy 6. Care of patients with Seizures 7. Care of patients with Spinal Trauma 8. Care of patients with Halo Traction 9. Care of patients with Cruthchfield Tongs GASTRO 1. Care, maintenance and insertion of NG Tubes 2. Care, maintenance and reinsertion of G Tubes 3. Care of patients with Duodenal Tubes 4. Care of patients with Blakemore Tube 5. Care of patients with Miller Abbot Tube 6. Care of patients with GI Bleeding RENAL 1. Care of Hemodialysis patients 2. Care of Peritonealdyalisis patients 3. Care of CAVH patients 4. Care of Supra Pubic Catheters 5. Care of patients with Renal Failure 6. Care of patients with Nephrectomy PHLEBOTOMY 1. Starting IV s 2. Using Heplock/Salinelock 3. Using Infusion Pumps 4. Administering Blood Products 5. Administering Hyperal/TPN

4 PHARMOCOLOGY QUIZ FOR RN s & LPN s A. Match the term with the definition that best describes the term 1. Maximum Dose The amount of a drug that can kill a patient 2. Initial Dose The largest amount of medication that can be given safely 3. Lethal Dose The amount of medication most effective with minimal side effects 4. Maintenance Dose The first dose B. Match the directions with each abbreviation 1. Three times a day AC 2. Before Meals OZ 3. After Meals q4h 4. By mouth OD 5. Four times a day TID 6. Every other day PC 7. Every four hours QID 8. Ounce PO 9. Right eye QOD C. Short Answer Give the full name of the abbreviated medication 1. ASA 2. MOM 3. KCL 4. TPN D. Multiple Choice Fill in the correct answer. If more than one answer may applies, circle all that are applicable. 1. When giving medication you should do which of the following? A. Give the right medicine B. Check the patient s identification bracelet C. Give the right dose D. Give it at the right time E. Check to see if it inactivates or potentiates another drug 1. a b c 2. a c d e 3. a b c d e 4. a b c e 2. Of the drugs listed below, which two should be checked with another nurse? A. Aspirin & Lasix B. Keflex & Prednisone C. Lanoxin & Insulin D. Valium & Demerol 3. When charting a PRN medication, what information should you provide? A. The medication given B. The exact time given C. The route of administration D. The patient s reaction to the drug

5 4. You are about to give a stat dose of Penicillin when the patient states, I m allergic to Penicillin. You should: A. Omit the dose until the patient is quiet B. Explain to the patient that there are many different Penicillins and this will not harm him C. Give the dose since the patient s doctor is aware of his/her allergy D. Delay the dose and notify the doctor 5. A medication is ordered TID, AC. This means it is to be given: A. 30 minutes before each meal B. 60 minutes after each meal C. 30 minutes after each meal D. 60 minutes before each meal 6. Information on the label of a bottle of Insulin will tell the nurse which of the following? A. The type of insulin B. The number of units per cc C. The expiration date D. The peak time of effect 7. What is the normal range for maintenance Lanoxin therapy? A. 0.25mg 5mg B. 1.25mg 5mg C..125mg -.25mg D. 1mg 2mg E. Assuming your patient is an adult, answer Too High, Too Low, or Normal for the following: A. Demerol: 50-75mg IM q4hrs prn pain B. Codeine: 200mg po q6hrs prn pain C. Aspirin: 600mg po or suppository q3-4hrs pain or fever D. Morphine: 15mg IM q4hrs prn severe pain E. Valium: 2.5mg q6hrs prn agititation (gen. population) F. Identify the following by their actions. 1. KEFLEX A) DIURECTIC 2. HEPARIN B) ANTI-ARRHYTHMIC 3. DILANTIN C) ANTICOAGULANT 4. VALIUM D) ANTIBIOTIC 5. PREDNISONE E) TRANQUILIZER 6. LASIX F) ANTIHYPERTENSIVE 7. TYLENOL G) ANALGESIC 8. DEMEROL H) ANTIPYRETIC 9. ALDOMET I) ANTICONVULSIVE 10. XYLOCAINE J) STEROID G. Calculations A doctor orders Phenobarbital gr. 1.5po. You have on hand gr. 0.5 tabs. How many tabs would you give? B. You are ordered to give D5w at 50 cc/hr IV. You are using micro-drip tubing (60gtts/cc). How many drops per minute? C. Give d5w at 50 cc/hr IV. You are using 15gtt/cc tubing. How many drops per minute go you give? SIGNATURE

6 Service Description for Licensed Nurse Contract Labor PHYSICAL REQUIREMENTS (F) Frequently (O) - Occasionally REQUIREMENT USED COMMENTS SIT, STAND, WALK, BEND, SQUAT (F) CHARTING, FEEDING AND TALKING TO PATIENTS, ALL INVOLVED IN PT. CARE CRAWL, CLIMB (O) IN CASE OF FIRE REACH ABOVE HEAD (F) HANGING IVs, FEEDING TUBES, REACHING MEDICINE CABINET, ETC. LIFT UNASSISTED UP TO 20 LBS (F) WORKING WITH EQUIPMENT LBS (O) OVER 50 LBS ASSISTANCE NECESSARY GRASPING USING BOTH HANDS (F) DAILY PT. CARE GIVE MEDICATIONS, BLOOD PRESSURE OPEN BOTTLES, AND WORKING WITH EQUIPMENT PUSHING/PULLING (F) WHEELCHAIRS, CARTS, BEDS FINE MANIPULATINGUSING BOTH HANDS (F) TREATMENTS, GIVE MEDS, USING EQUIPMENT, DAILY PT. CARE AND WRITING MOVE AROUND MACHINES (O) MACHINES IN PT s ROOMS MANIPULATING FEET AND USING BOTH FEET (F) USING FOOT LOCKS AND PEDALS ON BEDS, HOPPERS ANDHAMPERS EXPOSURE TO DUST, FUMES AND SHARP OBJECTS (O) DUST, CHEMICALS, SAFETY PINS, RAZORS, ETC REQUIREMENT CAN DISTINGUISH SMELLS CAN HEAR NORMAL TONES AND SOFT TONES CAN DISTINGUISH TEMPERATURES EYESIGHTNORMALORCORRECTED AND ABLE TO DO CLOSE EYE WORK SENSORY REQUIREMENTS COMMENTS/RELATED JOB DUTY FOUL ODORS ARE OFTEN SYMPTOMATIC OF THE DISEASE PROCESS OR INFECTION TELEPHONE ORDERS FROM DOCTORS, PT. CALLS & CALL BELLS MUST BE HEARD FROM NEAR AND FAR DISTANCES BLOOD PRESSURES, PULSES, ETC. TEMPERATURE OF EQUIPMENT, PT. TEMPS, BATHS, HEATING PADS, ICE PACKS, ETC. OBSERVING PATIENTS, GIVING PATIENT CARE, CHARTS, TESTS, B/P READINGS, GIVING MEDS, ETC. MENTAL REQUIREMENTS REQUIREMENT COMMENTS/RELATED JOB DUTIES READ, WRITE AND SPEAK NECESSARY MUST READ MEDICAL INFO., COMMUNICATE TO STAFF, PT s, AND DOCTORS IS COHERENT NECESSARY MEMORY AND RECALL NECESSARY CAN CONTROL EMOTIONS & HANDLE STRESS NECESSARY HAS POSITIVE ATTITUDE TOWARD THE ILL, NECESSARY ELDERLY, & THE HANDICAPPED ABLE TO WORK WITH CONTROLLED SUBSTANCES NECESSARY MUST DISPENSE CONTROLLED SUBSTANCES I have read and understand that the physical, sensory, and mental requirements outlined below are necessary of the services to be performed. I affirm I am able to perform the service without limitation and have not knowingly withheld any information relating to these requirements. SIGNATURE DATE

7 PATIENT S BILL OF RIGHTS-ELDER CARE ABUSE I feel each resident should expect the highest quality of personal and professional care. In keeping with this philosophy, I support and adhere to the Patient s Bill of Rights. Because of the importance of these expectations in my role, I am attesting to the portions of the Patient s Bill of Rights highlighted below which affirm the rights of a resident: 1. To be treated with consideration, respect and full recognition of personal dignity and individuality. 2. To receive care, treatment and services which are adequate. 3. To receive respect and privacy of his or her personal and medical records. 4. To be free from mental and physical abuse. 5. To enjoy privacy in his or her room. 6. To associate and communicate privately with persons of his or her choice and send and receive his or her personal mail unopened. 7. To meet with and participate in activities of social, religious and community groups at his or her discretion. No roster or rights can guarantee for the resident the kind of treatment they have a right to expect. It is very important that each of my actions is conducted with a main concern for the resident and the recognition of their dignity as a human being. Violations of the Patient s Bill of Rights may result in disciplinary action up to and including revocation of license, termination and jail. By signing this, I state that I have read and understand the Patient s Bill of Rights. SIGNATURE DATE

8 STATEMENT OF EMPLOYEE HEALTH STATUS AND INJURY HISTORY NAME TITLE Person to be notified in case of an emergency : Telephone number(s): Please answer the following by checking YES or NO. Use the space below to comment on any question you answered YES to. 1. Reactions to medications YES NO 2. Skin rashes or eczema YES NO 3. Back Trouble YES NO 4. Back Injury YES NO 5. Back Surgery YES NO 6. Back Pain on lifting YES NO 7. Knee Surgery YES NO 8. Swollen Joints YES NO 9. Rheumatism or arthritis YES NO 10. Dislocated shoulder YES NO 11. Fracture of a bone YES NO 12. Any other type of injury YES NO 13. Work related injury claim within the past five years? NO YES Please explain nature of injury, place, and date: Comments SIGNATURE DATE

9 HEPATITIS B VIRUS VACCINE CONSENT OR DECLINATION I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus infection (HBV). At this time I choose the following: Check one, then sign at the bottom. I have already received the vaccine and so I am declining at this time. I choose not to receive the vaccine at this time. I may chose to be vaccinated against Hepatitis B while working as an active Employee with Excel Staffing Services. I understand that I will be reimbursed for the cost of any shots in the Hep B series taken during the time I am working through Excel. In addition, I agree to request reimbursement while I am still actively accepting work and understand my request may be denied if it is made after I am terminated or inactivated for any reason. SIGNATURE PRINT NAME DATE

10 OSHA REGULATIONS AND GUIDELINES In accordance with OSHA regulations, each contractor must review the Blood Borne Pathogen, Hazard Communications, Emergency Action Plan, Fire Prevention and Escape Routes. Excel has notified each facility that they are responsible and must review their facility s specific plan with each contractor that works in that facility. Please review all enclosed material, sign and date this sheet. Fax or mail this sheet back to Excel for your personnel file. I have reviewed and understand the presented material as stated. I have been given the opportunity to clarify any questions that I may have. SIGNATURE DATE

11 EXCEL STAFFING SERVICES, INC. P. O. BOX GREENSBORO, NC FAX: INDEPENDENT PHYSICIAN, HEALTH CARE PROFESSIONAL AND VENDOR ACCESS AND CONFIDENTIALITY AGREEMENT HP113-B As a health care professional who treats patients and residents of facilities (hereafter referred to as Health Care Professional ), you may have access to confidential information. The purpose of this agreement is to confirm your understanding of and obtain your commitment to your duties regarding confidential information. Confidential information is valuable, sensitive, and protected by law and the facility policies. As a Health Care Professional, you are required to conduct yourself in a strict conformance to applicable laws and the facility policies and to abide by the duties described below governing confidential information. You will be responsible for any alteration, destruction, misuse or wrongful disclosure of confidential medical information by you and for any failure by you to safeguard any authorization codes to access confidential information. You understand that your failure to comply with the duties described below and this agreement may also result in loss of privileges to access confidential information, loss of privileges to treat patients and residents at facilities and to legal liability. As a Health Care Professional, you understand that you will have access to such confidential medical information that may include, but is not limited to, information relating to: Patients and residents (such as medical records, private conversations, admittance information, resident financial information, etc.) Other employees (such as salaries, employment records, disciplinary actions, etc.) Facility information (such as financial and statistical records, strategic plans, internal reports, memos, contracts, peer review information, communications, proprietary computer programs, source code, proprietary technology, etc.) Third party information (such as computer software programs, client and vendor proprietary information, proprietary technology, etc.). As a condition of and in consideration of your access to such confidential information, you promise that:. You will use confidential information only as needed to perform your legitimate duties at facilities. a You will only access confidential information needed to treat your patients and residents or fulfill your responsibilities.

12 b) You will not in any way divulge, copy, release, sell, loan, review, alter, or destroy any confidential information except as properly authorized within the scope of your professional activities as a Health Care Professional and treater of residents affiliated with facilities. c) You will not misuse or fail to safeguard confidential information. 2. You will safeguard and will not disclose any authorization codes or keys you have that allow you to access confidential information. You accept responsibility for all activities undertaken using your authorization codes or keys. 3. You will report to the Facility Privacy Officer activities by any individual or entity you suspect may compromise the confidentiality of confidential information described in this agreement. 4. You understand that your obligations under this agreement will continue after termination of your privileges or permission to treat patients and residents of facilities. You understand that facilities may review, revise or terminate your privileges to access and use confidential information as reasonably warranted to protect confidentiality of such information. 5. You understand that you have no right to ownership interest in any confidential information referred to in this agreement. The facility may at any time revoke your key, access code, other authorization, or access to confidential information. 6. Health Care Professional shall indemnify and hold facilities harmless from and against all claims, liabilities, judgments, fines, assessments, penalties, awards, or other expenses, of any kind or nature whatsoever. This indemnification includes without limitation, attorneys fees, expert witness fees, and costs of investigation, litigation or dispute resolution, relating to or arising out of any breach or alleged breach of this agreement by Health Care Professional. 7. You will respect ownership of proprietary software. 8. You will not operate any non-licensed software on any computer provided by any facility. By signing this, I agree that I have read, understand and will comply with this agreement. Health Care Professional Date Print Name

13 CONSENT FOR DRUG SCREENING I am aware that as a contract laborer, pre-employment drug testing is not necessary but that it may be requested that I voluntarily consent to a drug screening at my own expense. I hereby give my consent for this screening. Excel Staffing will give site location of where this service may be performed. I am also aware that I will be limited to the work offered if I do not have the test done before my shift is confirmed. SIGNATURE PRINT NAME DATE

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15 Please send my reference request to: EXCEL STAFFING SERVICES, INC. PO BOX GREENSBORO, NC TEL: FAX: REFERENCE REQUEST Company Name Supervisor Mailing Address City State Zip Telephone Number ( ) - For: Applicant s Name Job Title Tax ID/SS# - - I hereby authorize the employer named above to provide any requested information to Excel Staffing Services, Inc. and release them from all liabilities in responding to inquiries in connection with my application. Applicant s SIGNATURE DATE (Applicants do not fill out this portion.) TO BE COMPLETED BY EMPLOYER Dates of Employment: From To Position Held: Reason for Leaving: Would you rehire? YES NO If no please explain: Signature Date Title In placing an application with us for the position of, the above applicant has given you as a reference. It would be appreciated if you will complete this form and return it to us in the enclosed self addressed envelope. Thank you for your help.

16 Please send my reference request to: EXCEL STAFFING SERVICES, INC. PO BOX GREENSBORO, NC TEL: FAX: REFERENCE REQUEST Company Name Supervisor Mailing Address City State Zip Telephone Number ( ) - For: Applicant s Name Job Title Tax ID/SS# - - I hereby authorize the employer named above to provide any requested information to Excel Staffing Services, Inc. and release them from all liabilities in responding to inquiries in connection with my application. Applicant s SIGNATURE DATE (Applicants do not fill out this portion.) TO BE COMPLETED BY EMPLOYER Dates of Employment: From To Position Held: Reason for Leaving: Would you rehire? YES NO If no please explain: Signature Date Title In placing an application with us for the position of, the above applicant has given you as a reference. It would be appreciated if you will complete this form and return it to us in the enclosed self addressed envelope. Thank you for your help.

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22 NOTICE: THE EMPLOYEE ACKNOWLEDGES THAT HE OR SHE HAS READ THIS AGREEMENT AND UNDERSTANDS THAT THIS AGREEMENT INCLUDES AN AGREEMENT TO ARBITRATE DISPUTES (ARTICLE 6.1), A MAXIMUM OF A ONE-YEAR LIMITATION PERIOD FOR INITIATION OF ARBITRATION (ARTICLE 6.2), AND A CLASS AND COLLECTIVE ACTION WAIVER (ARTICLE 6.3), ALL OF WHICH MAY BE ENFORCED BY THE PARTIES. EMPLOYEE: (Signature) Date: EXCEL STAFFING SERVICE, INC. By: Its: Date:

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26 DON T FORGET! $$$$ 50 $$$$ $$$$ EASY MONEY $$$$ WE JUST WANTED TO REMIND YOU TO KEEP THOSE REFERRALS COMING! FOR EVERY NURSE OR CNA YOU REFER WHO APPLIES AND WORKS 40 HOURS, YOU WILL RECEIVE A $50 BONUS. THESE BONUSES ARE UNLIMITED! SO, BE SURE TO GIVE A COUPON TO EVERYONE YOU KNOW WHO WOULD LIKE TO WORK WITH EXCEL. FOR MORE INFORMATION, TO REQUEST ADDITIONAL COUPONS, OR TO CHECK ON A REFERRAL, CALL THE RECRUITING DEPARTMENT AT EXT 5. ************************************************************************ Referred by: your name, address & phone # Applicant s name, address, & phone # **This coupon must be attached to your referral s application in order to qualify for this bonus.

27 AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS) COMPANY COMPANY ID NUMBER I (WE) hereby authorize EXCEL STAFFING SERVICE, INC. hereinafter called COMPANY, To initiate credit entries and/or correction entries to our Checking Savings Account (select one) indicated below at the depository named below, hereinafter called DEPOSITORY, to credit the same to such account. DEPOSITORY NAME BRANCH CITY STATE BANK TRANSIT NUMBER (FIRST 9 DIGITS OFF CHECK BOTTOM) ACCOUNT NUMBER This authorization is to remain in full force until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY reasonable opportunity to act upon it. NAME(S) SIGNATURE TAX ID OR SOCIAL SECURITY NUMBER DATE SIGNATURE DATE

28 Attention Applicants Please complete the following and RETURN with the application Applicant Name: City & State: How did you hear about our company? Name of Newspaper: Name of Radio Station: Name of TV Station: Name of Friend: Phonebook: Name of Company Representative: We thank you for taking the time to fill this out and it helps us to provide better customer service in the future. Thank You Recruiting Department

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