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Date *Name *FirstLastEmail *PhoneAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDOB: *Are you 18 years or older? *YesNoHave you ever applied/worked here before? *YesNoCan you provide proof of eligibility to work in the United States? *Emergency Contact Name *Emergency Contact Phone Number *Referred By:Shift Preference: *First ShiftSecond ShiftThird ShiftSwingAnyLast 4 of SSN: *Type of Profession *RNLPNCNAOTHERNextHourly Rate Desired: *Past Employment *Past Employer Address: *Past Employer Phone Number: *Job Title and Duties: *Past Hourly Rate: *Supervisor *Reason For Leaving: *Are you presently Employed? *YesNoMay we contact your recent Employer? *YesNoEmployee Availability: *Type of Transportation: *CarBusOtherHow many hours are you willing to work? *When can you start work? *High School/College *Dates *What skills or additional training do you have that are related to the job for which you are applying? *NextDocumentation Required Attestation Forms The attestation form is used to document all training and credentials on your employee. The information and dates you enter on this form verifies to us that the employee file is complete and all components of the Strategic Healthcare Staffing Nurses (SHCSN) contract have been met. The attestation form ensures compliance in ten (10) key areas. To assist you in understanding what we require, we will discuss each of these areas separately. Employment Verification All candidates must have worked in their area of expertise for at least the past 12 months. You must submit to us the past 7 years of work history with the profile to include departments worked m. If they have worked for an agency, please include what facilities/ departments worked in/at. Licenses and Certifications Need to be current with expiration date. Professional licensure will not be accepted if there are stipulations and/or disciplinary action on current licensure. On occasion we may require a prior state license to verify that the employee does have one year of experience. Not only should you have a copy of an employee's current license, but you should also have accessed the appropriate web site (primary source verification) to verify licensure within 60 days of submission of profile, printed verification and maintained for your files. Also, primary source verification must be done with each renewal. BLS (CPR) - Must be current with the complete date of expiration. If only the month and year is on the card, we will enter the last day of the month for expiration. CPR cards must state that the course included infant, child and adult. The CPR card must also say Healthcare Provider. A "Heart saver" course or "On-Line" courses are not acceptable. Only American Heart and American Red Cross cards are acceptable. Area Specific Skills Checklist - This is an initial self-assessment of each employee's skills and should document all of their experiences within a given discipline. Checklist submitted must not be over a year old. An example of a PWMS skills checklist is attached, though you may use whatever skills checklist your agency uses. It is required that this skills checklist be revised/updated annually with a copy sent to Strategic Healthcare Staffing Nurses. Signature *Clear SignatureDate / Time *DateTimeNextHEPATITIS B DECLINATION FORM Please sign this form if: • You have chosen not to receive the 3 dose Hepatitis B vaccination and/or: • You have a negative Hepatitis B titer and are not immune to Hepatitis BIt is fully my choice to decline the Hepatitis B vaccine and I understand that by declining this vaccine, I will continue to be at risk of contracting Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials ·and I want to be vaccinated with The Hepatitis B vaccine, I will pursue the vaccination series at my own cost. DeclineProvide Proof of VaccinationSignature *Clear SignatureDate / Time *DateTimeNextDECLINATION FORM FOR SEASONAL INFLUENZA VACCINE My employer has recommended that I receive influenza vaccination in order to protect myself and the patients I serve. I DO NOT WANT A FLU SHOT. I acknowledge that I am aware of the following facts: • Influenza is a serious respiratory disease; on average, 36,000 Americans die every year from influenza-related causes. • Influenza virus may be shed for up to 24 hours before symptoms begin, increasing the risk of transmission to otllers. • Some people with influenza have no symptoms, increasing the risk of transmission to others. • Influenza virus changes often, making annual vaccination necessary. Immunity following vaccination is strongest for 2 to 6 months. • I understand that the influenza vaccine cannot transmit influenza and it does not prevent all disease. • I have declined to receive the influenza vaccine. I acknowledge that influenza vaccination is recommended by the Centers for Disease Control and Prevention for all healthcare workers in ordern to prevent infection from and transmission of influenza and its complications, including death, to patients, my coworkers, my family, and my community.Knowing these facts. I choose to decline vaccination at this time. I may change my mind and accept vaccination later, if vaccine is available. I have read and fully understand the information on this declination form. I understand that if I choose to decline the influenza vaccine, and my job duties may cause me to infect patients or to become infected, I will be required to wear a surgical mask or respirator, as appropriate, within 6 feet of patients or in designated areas during influenza season. I understand that I may change my mind at any time and accept influenza vaccination, if vaccine is available. DeclineProvide Proof of VaccinationSignature *Clear SignatureDate / Time *DateTimeNext Your Job Description Title *RNLPNCNARegistered NurseRegistered Nurse Job Responsibilities: Restores and promotes patient’s health by completing the nursing process. Collaborates with physicians and multidisciplinary team members. Provides physical and psychological support to patients, friends, and families. Identifies patient care requirements by establishing personal rapport with patients and their families. Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families. Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and hospital or regulatory standards. Resolves patient problems and needs by utilizing multidisciplinary team strategies. Maintains safe and clean working environment by complying with procedures, rules, and regulations. Protects patients and employees by adhering to infection-control policies and protocols; medication administration and storage procedures; and controlled substance regulations. Documents patient care services by charting in patient and department records. Maintains continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs. Maintains patient confidence and protects operations by keeping information confidential. Ensures operation of equipment by completing preventive maintenance requirements; calling for repairs; and evaluating new equipment and techniques. Maintains nursing supplies inventory by checking stock to determine inventory level. Maintains professional and technical knowledge by attending educational workshops and participating in professional societies. Maintains a cooperative relationship among health care teams by communicating information and participating in team problem-solving methods. Contributes to team effort by accomplishing related results as needed. Registered Nurse Qualifications/Skills: Clinical skills Bedside manner Infection control Physiological knowledge Administering medication Medical teamwork Multitasking, listening, and verbal communication Health promotion and maintenance Education, Experience, and Licensing Requirements: Registered Nurse (RN) Active applicable state licensure American Heart Association issued BLS and ACLS Clean background check and clean drug screenLPNDefinition and Nature of the Work LPN Licensed practical nurses (LPNs) help physicians and registered nurses (RNs) care for patients. They have the technical knowledge to perform routine nursing duties, but they may also make appointments, maintain patient records, and perform basic clerical duties. Their work allows doctors and registered nurses to devote their time to patient care that requires specialized knowledge. Most licensed practical nurses work in hospitals, nursing homes, other health care institutions, and private homes. Some are employed in doctors' offices, clinics, and public health agencies. Still others work in large businesses. They care for workers who have accidents or become ill on the job. Licensed practical nurses are also called licensed vocational nurses. Licensed practical nurses have a great deal of contact with their patients. It is important that nurses keep patients in good spirits. They also take patients' blood pressures, check temperatures, and apply bandages. In some cases LPNs may give their patients drugs that doctors have prescribed. Licensed practical nurses watch for changes in their patients' condition. If there is a change, they report it to the doctors immediately. Licensed practical nurses sometimes work in special units of a hospital. These include cardiac, burn, and maternity units. LPNs may be trained to use special equipment and may direct nurse's aides. On occasion, patients who are recovering from an illness hire licensed practical nurses to work in their homes. The nurses provide basic bedside care as well as follow the specific instructions of a patient's doctor. For example, they may give drugs on schedule or change bandages. In addition, they may prepare meals for patients. A licensed practical nurse works under the direction of registered nurses or doctors. Education and Training Requirements Must have at least 2 years of current experience with professional references and a clear Criminal background check with up to date credentials.Certified Nursing AssistantA Certified Nursing Assistant’s Job Responsibilities: • Provides for activities of daily living by assisting with serving meals, feeding patients as necessary and ambulating, turning, and positioning patients; and providing fresh water and nourishment between meals. • Provides adjunct care by administering enemas, douches, non-sterile dressings, surgical preps, ice packs, heat treatments, sitz and therapeutic baths; and applying restraints. • Maintains patient stability by checking vital signs and weight; testing urine and recording intake and output information. • Provides patient comfort by utilizing resources and materials; transporting patients; answering patients’ call lights and requests; and reporting observations of the patient to nursing supervisor. • Documents actions by completing forms, reports, logs, and records. • Maintains work operations by following policies and procedures. • Protects organization’s value by keeping patient information confidential. • Serves and protects the hospital community by adhering to professional standards, hospital policies and procedures; federal, state, and local requirements; and jcaho standards. • Updates job knowledge by participating in educational opportunities, reading professional publications, participating in professional organizations, and maintaining licensure. • Enhances nursing department and hospital reputation by accepting ownership for accomplishing new and different requests; and exploring opportunities to add value to job accomplishments CNA Skills and Qualifications: • Basic knowledge of anatomy, physiology, and medical terminology • Knowledge of relevant nursing care • Friendly and professional bedside manner • Maintains current CPR certification • Multi-tasking skills • Effective oral, written, and reading communication skills • Understands legal implications of patient care Education and Experience Requirements: • Certification with accredited training course through the State of Indiana and current certification through American Heart Association in Basic Life • 2 years of nursing assistant experience • Appropriate licenseSignature *Clear SignatureDate *Submit