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1120 Randolph St, Suite 42Thomasville, NC 27360
888-272-7427 Toll Free Phone866-743-6335 Toll Free Fax
Email: [email protected]: www.providencestaffing.com
EMPLOYMENT CHECKLIST
Here is a list of items that are needed to begin the interviewing process:
Employment Application Employment History or Current Resume’ Skills Checklist Copy of Driver’s License Copy of Social Security Card Copy of Current Nursing License(s) Copy of CPR Card and other Certifications Copy of Authorization Release Form Reference forms or Reference Letters (2)
When making copies, please make sure all copies are clear and legible with license numbers and expiration dates visible. Please copy both sides of all licenses and certifications. These are OSHA, DHEC and JCAHO mandates. Please return requested information via mail/fax/email. Thank you for choosing Providence Health Care Staffing.
Sincerely,Providence Health CareRecruiting Department
EMPLOYMENT APPLICATION(Please print or Type)
DATE:______________________________
Name:_______________________________________________________________________________Last First Middle Initial
Temporary Address:____________________________________________________________________Number Street City State Zip
Phone: ( ) _______________________ ______________________ Area Code Number Will Be At This Location Until Best times/Day to Reach You
Permanent Address:____________________________________________________________________Number Street City State Zip
Phone: ( ) _______________________ Birth Date:_____________ Area Code Number Best times/Day to Reach You
Referral Source/Name:_____________________ Email Address:___________________________ Friend, Magazine, Journal, Newspaper
U.S. Social Security Number:________________ Canadian Social Security Number:____________
Can you, upon employment, submit verification of your legal right to work in the United States? Yes No
EMPLOYMENT INFORMATION
RN LPN Tech Other Specialty:_____________________ Date You Can Begin:_______________
I am interested in a: Travel Assignment Permanent Position
Areas of Clinical Experience 1._________________ 2._________________ 3.__________________
Length of Experience in Above Areas: 1._________________ 2._________________ 3.__________________
Geographical Preference: 1._________________ 2._________________ 3.__________________
LICENSURE(Include copies of all state licenses) Original State:_______ License #:________________ Exp. Date:__________
State:____ License #:_______________ Exp. Date:______ State:______ License #:________________ Exp. Date:__________
State:____ License #:_______________ Exp. Date:______ State:______ License #:________________ Exp. Date:__________
Have you ever had disciplinary action taken against any of your state licenses? Yes No
Have you ever been named as a defendant in a malpractice claim? Yes No
Have you ever been convicted of a felony (other than a minor traffic violation) Yes No
If yes, on any of the above, please attach separate sheet with explanation.
EDUCATION Name and Location of School GraduatedY/N
Diplomas, Degrees Received
Nursing School
College
Graduate School
What month and year did you pass U.S. nursing boards/registration exams?___________ Canadian Nursing Boards?____________
Date CPR Certified:___________________________________________ CPR Expiration Date:_____________
Additional Certifications (i.e., ACLS, CCRN, etc.)____________________________________________________________________
EMPLOYMENT HISTORY (Please print or Type)
Name:_______________________________________________________________________________ Last First Middle Initial
Are you currently employed? Yes No If so, may we inquire of your present employer? Yes No
Please list your employment history below. If working through an agency, please indicate the specific facility in which you are working, the supervisor at the facility, as well as the name of the agency. You may include verifiable volunteer work. Please document reasons for periods of unemployment. Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________
Address:_________________________________________ City:____________________ State:______ Zip:_________
Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________
Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No
Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________
Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______
Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______
MEDICAL/SURGICAL SKILLS CHECKLIST KEY:
Place an X in the column best describing your expertise level according to the following scale:
1 - No Experience
2 - Limited Experience; Performs Intermittently
3 - Moderate Experience; Needs Resource for Backup
4 - Experienced; Performs Independently
1 2 3 4 1 2 3 4NEUROLOGICAL SYSTEM CARDIOVASCULAR SYSTEM - continued
Assess Cranial Nerves Care of Patients With:
Assess Level of Consciousness Acute CHF
Assess Sensory Motor Functions – Extremities Aneurysm
Assist with Lumbar Puncture Blood Lymph Disease
Care of Patients with: CVA
Acute Head Injury Cardiac Surgeries
Aphasia Femoral Bypass / Vascular Procedures
Autonomic Dysreflexia Pacemakers
CVA Transplant - Cardiac
Cancer of the Brain RESPIRATORY SYSTEM
Craniotomy Ambu Techniques
Head Trauma Apnea Monitor Usage
Impending D.T.s Assess Lung Sounds
Multiple Sclerosis Knowledge of Abnormal and Adventitious
Breath sounds Parkinson’s Care of Patients With:
Quadriplegia AIDS / Wheezing
Seizure Disorders CA of the Lung
Spinal Cord Injury COPD
Documentation of Seizures Emphysema
Halo Traction Pneumonia
Pre/Post Op Neuro Surgical Care TB
Seizure Precautions Transplant – Pulmonary
Shunts (i.e.: ventriculopertioneal) Chest Tube Maintenance and Care
Use of Anticonvulsants: IPPB Machine
IM Incentive Spirometer
IV Nebulizers
PO Oxygen Therapy:
Use of Glascow Scale Face Mask
CARDIOVASCULAR SYSTEM Nasal Cannula
Ability to perform 1 Person Rescue Precautions
CPR Adult Use of Portable Oxygen Tank
CPR Infant / Child Pulmonary Hygiene
Assess Heart Sounds (normal vs abnormal) Chest Physiotherapy (CPT)
Basic EKG Interpretation Determining Proper Catheter Size
Set-up / Run 12 Lead EKG Nasotracheal Suctioning
Use of Cardiac Monitor Oral Suctioning
Use of Doppler Tracheostomy Suctioning
Initiation of Arrest Procedure Thoracentesis
Administration of Meds During a Code Tracheostomy:
Changing Trach or Tube
Page 1 of 4
MEDICAL / SURGICAL SKILLS CHECKLIST – (continued)1 2 3 4 1 2 3 4
RESPIRATORY SYSTEM - continued GI / NUTRITION - continued
Tracheostomy (continued): Parenteral Feedings
Cleaning or Inner Cannula Complications Of
Emergency Management of Indications For
Dressing Changes Routes of Administration
S&S Of Infection Verification of Fluid & Caloric Requirements
Skin Care Use of Pumps for Parenteral Feedings
Ventilators List Types of Pumps
CPAP Brand:
PEEP Brand:
Portables Brand:
Pressure Pre-Set GU / REPRODUCTIVE / ENDOCRINE
Volume Pre-Set Bladder Irrigations
List Types of Ventilators: Bladder Training
Brand: Care, Maintenance & Removal of:
Brand: Indwelling Foley Catheter
Brand: Supra Pubic Catheter
Brand: 3-Say Catheter
GI / NUTRITION Care of Patients With:
Abdominal Drains Care and Maintenance AV Shunt / Fistula
Assess GI Status Bladder Disease
Bowel Training Cancer of Kidney
Care of Patients With: Cancer of Prostate
Anorexia Female Reproductive Organ Cancer
Bowel Disease Hysterectomy
Cancer of Colon Hypo/Hyperthyroidism
Cancer of Esophagus Mastectomy
Cancer of Rectum Nephrectomy
GI Bleeds Renal Failure
Hepatic Encephalopathy Transurethral Resection
Hepatitis Catheter Insertaion
Inflammatory Bowel Disease Male
Liver Failure Female
Liver Transplant Diabetic Care
Enemas (Fleets or Soapsuds) ADA Diet
Gastrostomy Tube Care: Blood Glucose Testing
G-Tube Change Foot Care
G-Tube Feedings Infection Prevention
Nasogastric Tube Care: Insulin Prep and Administration
Insertion / Reinsertation Education
N-G Tube Feedings Skin Care
Salem Sump S&S Hypo / Hyperglycemia
Nasla Intentinal Tubes (i.e. Miller-Abbot,
Cantor)
Urine Glucose Testing
Ostomy / Stoma Care Use of Blood Test Meters
Ostomy Irrigations Dialysis
Ostomy Patient Education Hemo
Paracentesis Peritoneal
Removal of Fecal Impactions Ileostomy Care
Urinary Diversions
Page 2 of 4
MEDICAL / SURGICAL SKILLS CHECKLIST – (continued)1 2 3 4 1 2 3 4
INTEGUMENTARY / ORTHOPEDIC INFUSION THERAPY - continued
Amputations / Stump Care Blood / Blood Products Administration
Assist In Use of Prosthetic Devices Calculate Dosages
Care of Patients With: Calculate Rates
Amputation Care of Central Lines:
Arthritic Disease Care of Insertion Site
Burns Dressing Changes
Pressure Ulcers Hanging IV Piggybacks
Gun Shot Infusion Procedures
Hip Replacement Pump Operations:
Incisions IMED
Knee Replacement IVAC
Laminectomy Other (specify):
Skin Cancer Record Keeping
Stab Wounds S&S of Complications
Cast Care S&S of Infection
Cast / Splint Application and Removal S&S of Infiltration
Circo-Electric Bed Insertion of Peripheral Line
Range of Motion Adult
Spika Cast Child
Stryker Frame Elderly
TENS Intralipids
Traction: Nursing Care, Maintenance of:
Skeletal Broviac Catheter
Skin Buretois
Transfers Heparin / Saline Lock
Wound Care: Insertion of Heparin / Saline Lock
Documentation of Wounds Hickman Catheter
Preventative Skin Care Peripheral Lines
Sterile Dressing Changes Porta-Cath
Use of Braden Scale Triple Lumen Catheter
Wound Enzyme Debriders OTHER NURSING RESPONSIBILITIES
Wound Irrigations Admission Procedure / Initial Assessment
ONCOLOGY Charge Nurse Responsibilities
Assessing Analgesic Effectiveness Discharge Planning & Teaching
Bone Marrow Transplant Injections
Counseling for: Preparation of Meds / Syringe
Altered Image Record Keeping
Grieving Process Site Prep / Rotation / Selection
Imagery Knowledge of Unit Dose
Relaxation Techniques Lab Value Interpretation
Morphine Pumps Pre / Post-Op Teaching
Narcotics via Continuous Infusion Primary Nurse Responsibilities
Radiation Therapy Problem Oriented Medical Records
Radioactive Implants SOAP Charting
Side Effects of Chemotherapy Team Leading
INFUSION THERAPY Universal Precautions / Procedures
Administration of Chemotherapy Use of Restraints
Administration of IV Meds
Page 3 of 4
MEDICAL / SURGICAL SKILLS CHECKLIST – (continued)OTHER NURSING RESPONSIBILITIES-continued CERTIFICATIONS Exp. DateSpecimen Collection ACLS
Arterial Blood Gas Draw BCLS
Arterial Blood Gas Values Interpretation Chemotherapy
Capillary Draw Diabetic Certification
Clean Catch Urine IV Therapy
Heelstick Med-Surg
Sputum Other
Stool Other
24 hr Urine via Indwelling Catheter Other
Venipuncture Wound Culture
SPECIALTY COURSE (NAME) DATE LOCATION1.
2.
3.
Detail any additional experience which makes you exceptionally qualified to practice as a traveling nurse.
What additional languages do you speak?
____________________________________________________________________________________
_____________________________________________________ ____________________________Traveler's Signature Date
Page 4 of 4
AUTHORIZATION RELEASE
I, ____________________________ authorize my employers, law enforcement agencies, school and/or persons who may assist Providence Health Care Staffing in determining my suitability for employment, to provide reference information to Providence Health Care Staffing. I hereby release all such employees, individuals, and/ or organizations contacted from all liabilities for issuing this information to Providence Health Care Staffing. I also authorize Providence Health Care Staffing to disclose this information to a client facility only after receiving my consent on each job opportunity.
____________________________ _____________________________ Applicant’s Signature Social Security Number
Dear Employer,
The individual named above has applied with Providence Health Care Staffing for employment in the healthcare field and has submitted your name for reference purposes. We would appreciate your reply and assure you that your answers will be held in strict confidence.
______________________________________ Providence Health Care Staffing Representative
1120 Randolph St, Suite 42Thomasville, NC 27360Phone: 888-272-7427Fax: 866-743-6335
REFERENCE FORM(Please print or Type)
TO BE COMPLETED BY TRAVELER
Applicant’s Name:_____________________________________________________________________
Classification: RN LPN CRTT RERT RTT Rad Tech ST CST
Clinical Specialty:_________________________________________________ Travel Assignment: Yes No
Employment dates: From:___________________________ To:__________________________________
Facility Name:_________________________________________________________________________________
City:_____________________________________________________________ State:_____________________
Contact:_____________________________________________________ Phone #: ( )_________________
TO BE COMPLETED BY FACILITY OR AGENCY
Please indicate whether the above information is correct: Yes No
Average patient caseload: ________________ # of beds on unit: _________ Charge Experience: Yes No
Teaching Non-Teaching # of beds in facility: _____________________________________
Reason for leaving: _______________________________________________ Would you rehire? Yes No
Please select a rating for each of the following:
Above BelowExceptional Standard Standard Standard
Performance Evaluation:1. Demonstrates competency in caring for patients……….. 2. Provides a safe and therapeutic patient environment… 3. Implements a coordinated plan of patient care………….. 4. Adheres to facility policies and procedures………………….. 5. Communicates appropriately with patients & families…. 6. Completes accurate documentation of patient care……..
Professional Attributes:7. Flexibility and adaptability…………………………………………….. 8. Willingness and ability to float (if applicable)………………. 9. Interest and enthusiasm……………………………………………….. 10. Ability to communicate with staff………………………………….. 11. Attendance and punctuality…………………………………………… 12. Overall professionalism………………………………………………….
Comments:____________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________ ____________________ ____________________ Evaluator/Title Date Phone
This information was obtained from: Written reference Verbal Reference
Evaluation Recommendation Letter
REFERENCE FORM(Please print or Type)
TO BE COMPLETED BY TRAVELER
Applicant’s Name:_____________________________________________________________________
Classification: RN LPN CRTT RERT RTT Rad Tech ST CST
Clinical Specialty:_________________________________________________ Travel Assignment: Yes No
Employment dates: From:___________________________ To:__________________________________
Facility Name:_________________________________________________________________________________
City:_____________________________________________________________ State:_____________________
Contact:_____________________________________________________ Phone #: ( )_________________
TO BE COMPLETED BY FACILITY OR AGENCY
Please indicate whether the above information is correct: Yes No
Average patient caseload: ________________ # of beds on unit: _________ Charge Experience: Yes No
Teaching Non-Teaching # of beds in facility: _____________________________________
Reason for leaving: _______________________________________________ Would you rehire? Yes No
Please select a rating for each of the following:
Above BelowExceptional Standard Standard Standard
Performance Evaluation:1. Demonstrates competency in caring for patients……….. 2. Provides a safe and therapeutic patient environment… 3. Implements a coordinated plan of patient care………….. 4. Adheres to facility policies and procedures………………….. 5. Communicates appropriately with patients & families…. 6. Completes accurate documentation of patient care……..
Professional Attributes:7. Flexibility and adaptability…………………………………………….. 8. Willingness and ability to float (if applicable)………………. 9. Interest and enthusiasm……………………………………………….. 10. Ability to communicate with staff………………………………….. 11. Attendance and punctuality…………………………………………… 12. Overall professionalism………………………………………………….
Comments:____________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________ ____________________ ____________________ Evaluator/Title Date Phone
This information was obtained from: Written reference Verbal Reference
Evaluation Recommendation Letter
REFERENCE FORM(Please print or Type)
TO BE COMPLETED BY TRAVELER
Applicant’s Name:_____________________________________________________________________
Classification: RN LPN CRTT RERT RTT Rad Tech ST CST
Clinical Specialty:_________________________________________________ Travel Assignment: Yes No
Employment dates: From:___________________________ To:__________________________________
Facility Name:_________________________________________________________________________________
City:_____________________________________________________________ State:_____________________
Contact:_____________________________________________________ Phone #: ( )_________________
TO BE COMPLETED BY FACILITY OR AGENCY
Please indicate whether the above information is correct: Yes No
Average patient caseload: ________________ # of beds on unit: _________ Charge Experience: Yes No
Teaching Non-Teaching # of beds in facility: _____________________________________
Reason for leaving: _______________________________________________ Would you rehire? Yes No
Please select a rating for each of the following:
Above BelowExceptional Standard Standard Standard
Performance Evaluation:1. Demonstrates competency in caring for patients……….. 2. Provides a safe and therapeutic patient environment… 3. Implements a coordinated plan of patient care………….. 4. Adheres to facility policies and procedures………………….. 5. Communicates appropriately with patients & families…. 6. Completes accurate documentation of patient care……..
Professional Attributes:7. Flexibility and adaptability…………………………………………….. 8. Willingness and ability to float (if applicable)………………. 9. Interest and enthusiasm……………………………………………….. 10. Ability to communicate with staff………………………………….. 11. Attendance and punctuality…………………………………………… 12. Overall professionalism………………………………………………….
Comments:____________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________ ____________________ ____________________ Evaluator/Title Date Phone
This information was obtained from: Written reference Verbal Reference
Evaluation Recommendation Letter