LPN Independent Contractor Personal Data Sheet

LPN Independent Contractor Personal Data Sheet Name (Last) (First) (Middle Initial) SSN License# State Issued Expiration Date License Received By: State Exam Endorsement Waiver Present Address: Street_ City State Zip Home Phone Number Work Phone Number Cell Phone Number Referred By Has Your Nursing License Ever Been Suspended or Revoked? Yes No If Yes Explain: Do You Have Malpractice Insurance? Yes No Policy # and Insurer WORK EXPERIENCE Please Check Areas You Have Worked in the last 2 Years ALCOHOL DETOX BURNS CARDIAC CARE DOCTOR S OFFICE ICU LABOR & DELIVERY MED/SURG MEDICATIONS NEUROLOGICAL NURSERY NURSING HOME ONCOLOGY OPERATING ROOM ORTHOPEDICS OB/GYN PEDIATRICS PYSCHIATRIC REHAB UROLOGY ER REFERENCES: GIVE BELOW 3 PERSONS IN THE NURSING PROFESSION, NOT RELATED TO YOU, WITH WHOM YOU HAVE WORKED AT LEAST ONE YEAR. 1. 2. 3. Name Address Relationship (i.e. Supv, co-worker) Years Acquainted I authorize you to contact all references, and I authorize all references to give you the requested information. Signature Date 1

SELF-ASSESSMENT OF AGE SPECIFIC CRITERIA Name: Position: The nursing professional must be able to demonstrate the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and other criteria appropriate to the age of the patient. The skills and knowledge needed to provide such care may be gained through education, training or experience. Please select the column that most accurately describes your proficiency level. Key: 1= Performs proficiently and independently. 2 = Some experience (assistance needed) OR Classroom training only. 3 = No training or experience. Infant/neonate Pediatric Adolescent Adult Geriatric Birth -1 Year 1 11 12 17 18-66 Over 66 CRITERIA (Circle One) Is Familiar with Normal Ranges 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 of vital signs Is Familiar with Standards of Care 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Based on Psychosocial Needs Includes Patients Family in Patient 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Education and Discharge Planning Assesses Patient s Specific 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Nutrition and Elimination Uses Teaching Methods that are 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Age Appropriate Demonstrates Communication 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Skills that are Age Appropriate Demonstrates Safety Measures 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 That are Age Appropriate _ Signature Date 2

LPN SKILLS CHECKLIST (GENERAL / MEDICAL / SURGICAL) Please Mark(X) the column that applies to your level of proficiency using the following code: A Trained and Skilled B Some Experience C No Experience MEDICATIONS: A B C Comments Unit dose Administer medications 1-10 patients Administer medications 11-20 patients Pediatric conversions Chemotherapy administration I.V. THERAPY: Heparin locks Initiate IV line and administer fluids CVP lines and dressing changes Insulin pump/syringes IMED pump IVAC pump Care of cut down IV additives/ IV piggy backs RESPIRATORY THERAPY: Suctioning Oro-naso-pharnyx Tracheostomy care OST equipment (mask/canullas) Aerosol treatments GI TUBES: G.U.: Naso-Gastric Miller-Abbot Blakemore(Minnesota) (for bleeding varices) Assessment of bowel sounds Catheters Foley Insertion (male and female) Suprapubic ORTHOPEDICS: Bucks traction Circo electric bed Crutchfield traction Balanced traction Cast care Clinitron bed ADDITIONAL NURSING SKILLS: Administering blood products Venipunctures Neurological check Experienced initiating CPR Experience assisting with cardiac respiratory arrest procedure Administering enteral nutrition Administration of total parenteral nutrition Care of Hickman catheter 3

Medical Evaluation Have you had any of the following? Check each item Yes or No. YES NO YES NO Allergy to drugs Head Injury Which Drugs? Hearing or ear trouble Anemia or blood disorder Heart trouble Back trouble High blood pressure (If you were under doctor's care, give date.) Kidney or bladder trouble Asthma Liver diseases or jaundice (Hepatitis) Blackouts or Dizziness Lung trouble Bone or joint trouble Shortness of breath Breast disorder Nervous breakdown Bowel trouble or change Abnormal heart beat Cancer or tumor Hemorrhoids, rectal disorder Chest pain Recent change in weight (loss or gain Chronic cough of 15 lbs or more in the last 6 months Recent chills or fever Rheumatic fever Frequent colds Rheumatism or arthritis Circulatory troubles Hernia or rupture Chronic diarrhea Chronic nose or sinus trouble Corrected eye lenses Swallowing trouble Coughing or vomiting blood Stomach trouble or vomiting Deformities or paralysis Sugar or albumin in urine Diabetes Eye trouble Swelling of ankles or feet Emotional problems Teeth problems Epilepsy Throat or thyroid problems Foot trouble Tuberculosis ( or positive skin test) Headache problems Varicose Veins Indigestion problem Venereal Disease Gall Bladder disorder Weakness Hay fever Skin trouble, rashes, boils, fever blisters YES NO If Checked "yes", give details in the space provided below with, condition, etc.) Have you ever been hospitalized? Explain hospitalizations and list surgeries. Have you ever been refused life insurance, or had to pay an increased premium? Have you ever been turned down by or discharged from the armed services for medical reasons? (Date entered) (Date discharged) Have you ever filed a compensation claim or received benefits as a result of an industrial injury or disease? Have you missed a total of ten days work during the past 2 years for illness or injury? Have you any physical or mental complaint at present? Has your work ever been restricted because of your health? Are you taking any medicine or drug now? Which ones? Have you been advised to have any diagnostic test, hospitalization, treatment or surgery which has not been completed? Have you any problems you would like to discuss? What is your current weight? Height? 4

INDEPENDENT CONTRACTOR AGREEMENT This Independent Contractor Agreement is entered into by and between Tri-State Nurse Staffing Agency, LLC ( TNSA ) and ( Contractor ). The parties hereby agree as followed: 1. TNSA will represent Contractor in finding, on an as needed basis, temporary professional nursing work with hospitals, nursing homes, and other healthcare institutions ( Medical Facilities ). Contractor desires TNSA to provide this representation. 2. Contractor is not obligated to take any work which is found through TNSA s representation of Contractor. If Contractor does agree to take such work, Contractor may subcontract this work to another independent contractor if Contractor is subsequently unable or unwilling to perform this work. 3. Contractor shall be paid for the work performed at the medical facilities on an hourly basis after the work has been performed by Contractor. 4. Nothing contained herein shall be interpreted or construed to create an employer-employee relationship between TNSA and Contractor. TNSA shall not control in any manner whatsoever the work performed by Contractor for the Medical Facilities. Contractor shall provide and use his or her own tools and equipment that may be necessary to perform the work for the Medical Facilities. TNSA shall not be liable to Contractor for any expenses paid or incurred by Contractor unless otherwise agreed in writing. TNSA shall not withhold state or federal income taxes, social security taxes, or any kind of payroll taxes on behalf of Contractor. TNSA is not responsible for workers compensation insurance for Contractor. Contractor shall pay for his or her malpractice insurance. 5. Contractor is free to be represented by another company like TNSA, to provide independent contractor work directly to the Medical Facilities, or to be an employee of the Medical Facilities. 6. This Contract shall be from month to month. Either party may terminate this Contract by giving the party a written notice to terminate no later than one week prior to the end of the month. 7. Contractor declares that he or she is duly licensed as a Registered Nurse, a Licensed Practical Nurse, or a Certified Nursing Assistant and has complied with all federal, state and local laws with respect to providing the professional nursing services contemplated by this agreement. 8. This Agreement contains the entire agreement of the parties and cannot be changed except by a writing signed by both parties. This Agreement shall be construed and interpreted in accordance with the laws of the State of Tennessee. This Independent Contractor Agreement is hereby entered into on the Day of, Tri-State Nurse Staffing Agency, LLC By: Contractor By: 5

Name Social Security Number HEPATITIS B VACCINE REFUSAL I know that a serious disease, Hepatitis B, may result from the contamination of my blood by needle sticks or other injuries that may expose my blood to Hepatitis B. I also understand that the Center for Disease Control has recommended prophylactic measures for all health care workers regarding Hepatitis B. In compliance with this guideline, Tri-State Nurse Staffing Agency, LLC has recommended that I take the Hepatitis B vaccine series. I have read the above and understand the dangers of Hepatitis B. I refuse to take the prophylactic treatment. SIGNATURE DATE WITNESS DATE If you have received the Hepatitis B Vaccine please attach record of immunization. Dose 1 Dose 2 Dose 3 Date Date Date 6

REFERENCE / RELEASE #1 Applicant Name Position Applying For Former Employer Phone # Facility Address Applicant s Authorization The nursing professional listed above has named you as a reference. Tri-State Nurse Staffing Agency, LLC would appreciate your time to verify and evaluate this person. All information will be held in strictest confidence: I hereby consent to and authorize the above former employer, its agents and employees to furnish and release of any information concerning my work history to Tri-State Nurse Staffing Agency, LLC. I hereby release the above named former employer, its agents and employees from all liability claims which arise or result from any information provided pursuant to this authorization. Applicant s Signature Date Record of Employment Position Held Date of Hire Separation Date Reason for separation of employment Eligible for Rehire Yes No Summary of Essential Duties _ Have you worked with the above referenced person? Yes No In what capacity? Excellent Good Average Fair Poor Job/Skill Knowledge Quality/Accuracy Attendance/Punctuality Dependability/Productivity Appearance/Attitude Comments Former Employer Signature Title Date 7

REFERENCE / RELEASE #2 Applicant Name Position Applying For Former Employer Phone # Facility Address Applicant s Authorization The nursing professional listed above has named you as a reference. Tri-State Nurse Staffing Agency, LLC would appreciate your time to verify and evaluate this person. All information will be held in strictest confidence: I hereby consent to and authorize the above former employer, its agents and employees to furnish and release of any information concerning my work history to Tri-State Nurse Staffing Agency, LLC. I hereby release the above named former employer, its agents and employees from all liability claims which arise or result from any information provided pursuant to this authorization. Applicant s Signature Date Record of Employment Position Held Date of Hire Separation Date Reason for separation of employment Eligible for Rehire Yes No Summary of Essential Duties _ Have you worked with the above referenced person? Yes No In what capacity? Excellent Good Average Fair Poor Job/Skill Knowledge Quality/Accuracy Attendance/Punctuality Dependability/Productivity Appearance/Attitude Comments Former Employer Signature Title Date 8

***INFORMATION NEEDED TO COMPLETE YOUR FILE*** 1. COPY OF PROFESSIONAL LICENSE 2. COPY OF PHYSICAL WITHIN LAST 12 MONTHS 3. COPY OF PPD OR CHEST X-RAY LAST 12 MONTHS 4. COPY OF DRIVERS LICENSE 5. COPY OF SOCIAL SECURITY CARD 6. COPY OF CURRENT CPR CARD 7. COPY OF MOST RECENT DRUG SCREEN 10 PANEL 8. COPY OF MOST RECENT BACKGROUND CHECK 9. RESUME INCLUDING JOB HISTORY & EDUCATION 10. COPY OF W-9 9