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WE are an EQUAL OPPORTUNITY EMPLOYER

Please advise us if you need accommodations completing this application.

 

Full Name: *   Maiden Name/Alias (if applicable):
Address: * City: *
State: * Zip: *

     
I have been a resident of  *  for  *  years.
     
Home Phone: *
 Cell/Beeper:
Alternate #: Email Address:
     
I, * , understand scheduling assignments will be done via phone and/or email and agree to return calls placed to the number(s) listed above so as to confirm work schedule. Schedules will not be confirmed via email.
     
License/Certification #: * State Issued:
*
Exp. Date: *
 
Do you maintain licensure from another state? * No   Yes
If yes, which state?
 
I, * , understand it is a policy of NurSTAT to research and confirm all information regarding my license/certification via State Board of Nursing/Nurse Aide Registry, OIG and EPLS. To the best of my knowledge, the above information is correct and free from any legal implications.
 
Have you previously or currently have any malpractice claims and/or suits filed against you? * No   Yes
 
If yes, please explain:
 
Are you at least 18 years old? * No   Yes
 
Do you have access to transportation? * No   Yes
 
Do you have a driver's license? * No   Yes
 
Driver's License #: State:
Exp. Date:
 
Have you been a resident of your state for at least two consecutive years? * No   Yes
 
Have you been charged and/or convicted* of a crime, other than a traffic violation, within the last 7 years? * No   Yes
 
If yes, please explain:

* Conviction will not necessarily disqualify applicant from employment

 
How were you referred to NurSTAT?

If referred by NurSTAT employee, please list name on line above

 
Next of Kin/Emergency contact: Phone #:
 
Are you capable of performing the activities in the job for which you have applied? * No   Yes



Education

High School *    
School Name: City:
State:
 
Graduated? No   Yes   GED

College    
School Name: City:
State: Degree/Major:
 
Graduated? No   Yes   GED

Other    
School Name: City:
State: Degree/Major:
 
Graduated? No   Yes   GED



Previous Employment
list your 3 most recent employers:

Employer One *    
Date From: Date To:
Name of Employer: Phone Number:
Supervisor: Position:
Salary:
Reason for Leaving:


Employer Two *    
Date From: Date To:
Name of Employer: Phone Number:
Supervisor: Position:
Salary:
Reason for Leaving:


Employer Three *    
Date From: Date To:
Name of Employer: Phone Number:
Supervisor: Position:
Salary:
Reason for Leaving:



Personal References
Preferably co-workers; No Family

Reference One    
Name Phone Number:
Occupation: Number of Years Known:
 
Did you, or are you currently working with reference? No   Yes
 
Where?


Reference Two    
Name Phone Number:
Occupation: Number of Years Known:
 
Did you, or are you currently working with reference? No   Yes
 
Where?


Reference Three    
Name Phone Number:
Occupation: Number of Years Known:
 
Did you, or are you currently working with reference? No   Yes
 
Where?


*   I certify that answers given herein are true and complete to the best of my knowledge. I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.
 
* I authorize investigation of all references and statements contained in the application for employment, as they are necessary in arriving at an employment decision, and release all obligations to those individuals providing such reference.
 
* I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon the satisfactory outcome of a medical examination and criminal background check.
 
* I understand that if I am offered employment, I will be working for NurSTAT on it�™s payroll, and employment is based on client requests for staff relief. I have been made aware of the area NurSTAT provides supplemental service to, and that assignments will be offered based on our clients needs. I understand there are no guarantee of hours, that I am an at-will employee and employment may be terminated by NurSTAT or self at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination.


Experience/Age Specific Competency

Directions: For each category, check box if you have experience, followed by the number of years�™ experience.

Please indicate number of years in which you have experience with the following:
Unit Years Min Exp Needed Type Needed Mandatory Certs Preferred Certs
ACUTE HOUSE
SUPERVISOR		 2 SUPERVISOR EXP, 5
YRS OVERALL
ACUTE CARE
NURSING EXP		 BLS, ACLS, PALS,
CPI, JCAHO
STANDARS		 BSN, CLINICAL CERT, STATE
REGS, HIPAA
ACUTE REHAB 1 M/S OR ACUTE
REHAB		 BLS REHAB EXP
ACUTE EPILEPSY 1 MS, TELE OR
EPILEPSY		 BLS, ACLS EPILEPSY MONITORING
ALCOHOL REHAB 1 ALCOHOL REHAB BLS  
BARIATRIC I 1 TELE & MS BLS ACLS
BARIATRIC II 2 TELE & MS & 1 ICU BLS, ACLS  
BONE MARROW 1 BM PREFERRED W/
ONCOLOGY		 BLS ACLS, CHEMO
BURN 1 BURN UNIT BLS, ACLS, BURN
COURSE		 CRITICAL CARE COURSE
CARDIAC CATH LAB 1 CURRENT CATH
LAB/ 1 YR EXP IN
INTERVENTIONAL
CC LAB AND EP
LAB		 BLS, ACLS, IABP,
MODERATE
SEDATION,
CRITICAL CARE		 CURRENT EXP IN CC,
CARDIAC, ARRHYTHMIA,
PERIPHERAL VASCULAR
INTERVENTION, CC COURSE;
KNOWLEDGE OF IVUS, RADI,
ICU, CARTO, CRYOCATH
CARDIO VASCULAR
OR		 2 CVOR, EXP W/
BALOON PUMPS
REQUIRED		 BLS, ACLS,CCRT CORN, BALLOON PUMP EXP.
CASE MANAGER 2 RN & 1 CM CASE MGT OR UR BLS  
CHARGE NURSE 2 CHARGE NURSE BLS ACLS, CC COURSES
CLINIC/AMBULATORY 1 BCLS BLS  
CCU 1 CURRENT CC BLS, ACLS CC COURSE
CVICU/OHRU �"
Cardiovascular ICU		 2 W/ RECENT CVOR CVOR, EXP W/
BALOON PUMPS
REQUIRED		 BLS, ACLS, CCRT  
DIALYSIS 2 CURRENT DIALYSIS BLS ACLS
DRUG REHAB 1 DRUG REHAB BLS  
ER (NON-TRAUMA) 2 ER BLS, ACLS,PALS ATLS, TNCC, CPI
ER (LEVEL I & II
TRAUMA)		 1 CURRENT TRAUMA
ER		 BLS, ACLS, PALS,
TNCC		 ATLS, CPI
ENDOSCOPY 1 CURRENT CC BLS, ACLS CONSCIOUS SEDATION
COURSE
GI LAB 1 GI LAB BLS, ACLS  
HIV/AIDS     BLS  
HOSPICE 2 NO PD �" NEED HH
OR HOSPICE		 BLS  
ICU �" INTENSIVE
CARE UNIT		 1 CURRENT CC BLS, ACLS CC COURSE
INTERVENTIONAL
RADIATION		 1 CURRENT CC, ER,
ICU OR IR EXP		 BLS CC COURSE
LABOR & DELIVERY 1 L&D W/ C-SECTION
SCRUB		 BLS, NRP, FETAL
MONITOR
COURSE		 NRP/NALS
LABOR & DELIVERY
(HIGH RISK)		 3 L&D BLS, ACLS,
NRP/NALS,
FETAL MONITOR
COURSE		 ANTENATAL/HIGH RISK EXP.,
AWHONN FETAL HEART
MONITORING P&P & CERT AS
AN INPATIENT OB
SPECIALIST (RNC)
MEDICAL/SURGICAL 1 MED/SURG BLS  
MD OFFICE 1 MD OFFICE BLS  
MHMR 1 MHMR BLS  
MICU - MEDICAL ICU 1 CURRENT CC BLS, ACLS CC COURSE
NEONATAL NURSERY 1 NEWBORN NURSERY BLS NRP/NALS
EURO/TRAUMA ICU 2 CURRENT ICU; NEURO/TRAMA PREFERRED BLS, ACLS TNCC OR CNRN
NURSING HOME 1 CURRENT NH OR ASL BLS IV CERTIFICATION
NH SUPERVISOR 2 SUPERVISOR EXP BLS, IV CERTIFICATION
NICU �" NEONATAL ICU 1 CURRENT NICU BLS, NRP/NALS NICU COURSE
ONCOLOGY 1 ONCOLOGY BLS, CHEMO ONCOLOGY
OPEN HEART 1
OR 2 OR BLS, ACLS, PALS CORN
ORTHO 1 ORTHO BLS
OUTPATIENT SURGERY I 1 MED SURG OR PACU BLS ACLS
OUTPATIENT SURGERY II 1 GI RECOVERY BLS, ACLS
PCU - PROGRESSIVE CARE UNIT 1 TELE BLS, ACLS, EKG COURSE CC OR TELE COURSE
PEDIATRICS 1 PEDS BLS, PALS
PEDIATRIC ER 1 2 PEDS, 1 PED ER OR ICU BLS, PALS
PICU (LEVEL II & III) �" PEDIATRIC ICU 1 CURRENT PICU BLS, PALS PICU COURSE
PACU - POST ANESTHESIA RECOVERY ROOM 1 CURRENT CC BLS, ACLS, PALS
POST PARTUM �" OB/GYN 1 POST PARTUM REQ, MS BLS
PSHU �" PED SURG HEART UNIT 2 CURRENT PSHU BLS, PALS
PSYCH (GENERAL) 1 CURRENT PSYCH BLS, NON- VIOLENT CRISIS INTERVENTION COURSE
PSYCH (GERIATRIC) 1 CURRENT PSYCH BLS, NON- VIOLENT CRISIS INTERVENTION COURSE
PTCA RECOVERY �" PERCUTANEOUS CORONARY ANGIOPLASTY 1 CARDIAC CATH LAB BLS, ACLS
SCRUB NURSE 2 CURRENT IN SURGERY/OR BLS, OR CERT ACLS
SHORT PROCEDURE/ STAY (PREP & HOLD) 1 MED/SURG BLS IV CERT
SICU - SURGICAL ICU 1 CURRENT CC BLS, ACLS CC COURSE
SNF 1 MS, LTC/SNF BLS, IV  
SOLID ORGAN 1 TRANSPLANT BLS, ACLS
STEP DOWN/ TCU 1 CURRENT CC BLS, ACLS CC COURSE
SURGERY �" 1ST ASSISTANT 2 SURGICAL 1ST ASSISTANT EXP AS 1ST ASST CERTIFIED 1ST ASST.
TELEMETRY I 1 MED/SURG BLS ACLS
TELEMETRY II 1 TELE BLS, ACLS, EKG COURSE
UR (UTILIZATION REVIEW) 1 BLS BLS ACLS

 

Abbreviations
BLS BASIC LIFE SUPPORT/ CPR
ACLS ADVANCED CARDIAC LIFE SUPPORT
NRP NEONATAL RESUSATATION PROGRAM
NALS NEONATAL ADVANCED LIFE SUPPORT
PALS PEDIATRIC ADVANCED LIFE SUPPORT
CPI CRISIS PREVENTION & INTERVENTION
IABP INTRA AORTIC BALLOON PUMP
CVOR CARDIOVASCULAR OR
CCRT CRITICAL CARE RESPONSE TEAM
CORN CERTIFIED OR NURSE
ATLS ADVANCED TRAUMA LIFE SUPPORT
TNCC TRAUMA NURSING CORE COURSE
AWHONN ASS. OF WOMENS HEALTH OBSTETRIC & NEONATAL NURSES
CNRN CERTIFIED NEUROVASCULAR RN

 

Please check below for each age group for which you have expertise in providing age-appropriate nursing care:
A. Newborn/Neonate (up to 30days) D. Preschooler (3-5yrs) G. Young Adults (18-39yrs)
B. Infant (30days �" 1yr.) E. School Age Children (5- 12yrs) H. Middle Adults (39-64yrs)
C. Toddler (1-3yrs) F. Adolescents (12-18yrs) I.  Older Adults (64+)

 

Experience with Age Groups:

Able to adapt care to incorporate normal growth and development:
A    B    C    D    E    F    G    H    I

Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level:
A    B    C    D    E    F    G    H    I

Can ensure a safe environment reflecting specific needs of various age groups:
A    B    C    D    E    F    G    H    I


Additional Credentialing
TYPE CURRENT EXPIRATION DATE COMMENTS
CPR  
First Aide Certification  
BCLS  
ACLS  
IV Certification  
PALS  
Liability Insurance  
Other:  
Other:  

 

List courses taken in addition to your license/certifications:


Criminal History Background Report

30-Day Provisional Hire Form/Affidavit

Agencies may employ applicants on a provisional basis for a single period not to exceed 30 days.
I, , have been a resident of for consecutive years.
 

PA Residents:

I, , swear and affirm that I have not been charged or convicted of any offenses contained in Act 169 of 1996 as Amended by Act 13 of 1997 (see reverse) as outlined by the Commonwealth of Pennsylvania. The effective date of the act is July 1, 1998.

I DO UNDERSTAND that a PA Criminal Record Check will be requested via PA State Police Criminal History Files.
A fee of $10.00 will be deducted from my first paycheck.
 

FL Residents:

I, , swear and affirm that I have not been charged or convicted of any offenses contained in Florida Statutes, Title XXXI Chapter 435 and Title XXIX Chapter 408.

I DO UNDERSTAND an FDLE Level II Criminal History Request will be completed via AHCA.
A fee of $29.00 will be deducted from my first paycheck.
 
I DO NOT currently live out-of-state.

 

 

You may be required to obtain an FBI/FDLE Level II check. The office will notify you of such.

The following information is necessary when processing the background clearance:
Employee Name (Last, First Middle Initial):
Maiden/Alias Name:
 Birthday:
 Gender:
 Race:


Authorization
Initials: *   Date: *

 


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