CNA Independent Contractor Personal Data Name SSN: (Last) (First) (Middle Initial) 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 Date of Physical Exam Date of Last Chest X-Ray or PPD Test Do you have any impairments, physical or mental, which would interfere with your ability to perform the assignments for which you have applied? Yes No If Yes, please describe: Do You Have Malpractice Insurance? Yes No Policy # and Insurer Have you ever been convicted of a crime, excluding misdemeanors and summary offenses? Yes No If Yes, describe in full Educational Background Name & Address Dates Attended Graduate? Major High School Vocational/Tech Hospital College and University Signature Date 1
CNA Independent Contractor Personal Data Former Employers - List Below Last Four Employers, Starting With Last One First (Medical Field Only) Date Name and Address of Employer Salary Position Month and Year Reason for Leaving REFERENCE: Give Below the Names of the Three Persons in the Nursing Profession, Not Related You, Whom You Have Known at Least One Year Name Address Relationship (Supv., Co-Worker) Years Acquainted WORK EXPERIENCE Please check areas you have worked in the last 2 years. MED/SURG SKILLS CHECKLIST Please check the appropriate response Yes No BACK RUBS Yes No ENEMA MEAL PREPARATION PATIENT WEIGHING S TPR 2
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: 3
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 4
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 5
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 6
***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 7