SURVEY

Job Code or Position Applied For

Where did you hear about us?    

 

PERSONAL INFORMATION

Last Name:   

First Name:   

Middle Initial:

 

Street Address/Apt:

                      City:

                    State:

                       Zip:

 

     Home Phone:

Alternate Phone:

   Email Address:

The next few requested data are collected for client/patient matching purposes and are optional.

DOB:            Gender: M  F

         mm/dd/yy

 

Height:         Weight:

           (ex. 5'7".)                          (ex. 150 lbs)

 

Ethnicity:

Language other than English:

Preferred working days: Mon Tue Wed Thu Fri Sat Sun

Preferred working hours:

Preferred working shifts: Live-in  Open

                                    7a - 3p 3p - 11p  11p - 7a

                                    7a - 7p 7p - 7a

Do you have a valid driver's license?  Yes  No

Do you have a car available for work? Yes  No

If yes, please specify make/model and year:

Make/Model:   Year:

Does your car have full coverage insurance? Yes  No

** Proof of full coverage insurance required

     when transporting patients.

PROFESSIONAL DATA:

 

Classification: RN  LVN  CNA  HHA  Caregiver

Other (please specify)

 

If RN, check all that apply:

ICU/CCU   E.R.        D.O.U.    MED/SURG    PEDS

L & D       NICU       O.R.       Recovery       Psych

ISU          Oncology Geriatric Post Partum 

Other/Specify:

 

Other Certification/Training, check all that apply:

Current ACLS  Basic EKG   Neonatal Training Fetal Monitoring

Other:    Other:

 

1st Aid Exp Date:

    CPR Exp Date:

EDUCATION/TRAINING

High School: 

Date Graduated: Years Attended:

                          (mm/dd/yy)                     ex. (5yrs or 6mo)

 

College/Univ:

Date Graduated: Years Attended:

Degree:

 

Other/Training:

Date Graduated: Years Attended:

Degree/Certification:

EMPLOYMENT HISTORY

** List the last 5 years or last 3 employers starting with the most recent one.

Employer:

Address:  

Phone:    Position:

Inclusive Dates:

 

Employer:

Address:  

Phone:    Position:

Inclusive Dates:

 

Employer:

Address:  

Phone:    Position:

Inclusive Dates:

REFERENCES

** List at least three (3) people other than your friends or relatives that we can contact for reference.

Name: Phone:

Address:

 

Name: Phone:

Address:

 

Name: Phone:

Address:

OTHER

Have you ever been convicted of any crime? If yes, explain below.

 

Have you ever applied for supplemental staffing before? If yes,

    enter agency name and inclusive dates below.

 

Do you have any health conditions that may affect or impair your

  ability to work? If yes, explain treatment or medications below.

 

Use the space below for special notes you want us to know about

   that may be related to the position you are applying for.