Sports

APPLICANT INFORMATION EDUCATION NAME & LOCATION OF SCHOOL NURSING SPECIALTY. Date m/dd/yy. Last Name First M.I. Permanent Street Address

Categories
Published
of 15
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Share
Description
APPLICANT INFORMATION Last Name First M.I. Other Name under which you have been employed Best Time to Reach you Date m/dd/yy Permanent Street Address Apartment/Unit # City State Zip Temporary Address Apartment/Unit
Transcript
APPLICANT INFORMATION Last Name First M.I. Other Name under which you have been employed Best Time to Reach you Date m/dd/yy Permanent Street Address Apartment/Unit # City State Zip Temporary Address Apartment/Unit # City State ZIP Phone Work Phone Date Available to Work Position Applied for. Social Security No. Cell Phone Address Desired Rate of Pay Are you a citizen of the United States? Have you ever worked for this company? Have you ever been convicted of a felony? EDUCATION NAME & LOCATION OF SCHOOL If no, are you authorized to work in the U.S.? If so, when? If yes, explain College City/State From To Did you graduate? Diplomas/ Degrees Graduate School City/State From Other School (if applicable) From To To Did you graduate? Did you graduate? City/State Diplomas/ Degrees Diplomas/ Degrees NURSING SPECIALTY Type of Specialty Type of Specialty Type of Specialty Type of Specialty Type of Specialty Years of Experience Years of Experience Years of Experience Years of Experience Years of Experience Shift Preference 12o 8o Days Eves Nocs PROFESSIONAL LICENSE AND CERTIFICATIONS License Number State Expiration Date License Number State Expiration Date 1 of 15 PROFESSIONAL LICENSE AND CERTIFICATIONS (continued) License Number State Expiration Date License Number State Expiration Date License Number State Expiration Date ADDITIONAL INFORMATION Has your license ever been investigated, suspended, or revoked in any state? Yes No Have you ever been convicted of a crime? Yes No Have you ever been named as a defendant in a professional liability action? Yes No If yes, to the above statements, please attach separate sheet with full explanation. Have you/are you attending an Employer Substance Abuse Program? Yes No CERTIFICATIONS Check all applicable certifications and enter expiration date: Have you passed NCLEX? Yes No Current Cards: Expiration Date Current Cards: Expiration Date Current Cards: Expiration Date ACLS ENPC CRRN BLS CATN CCRN PALS CR CNRN NALS CEN RNC NRP Chemo FHM TNCC OCN Other License/Certifications PREVIOUS EMPLOYMENT 1 Facility Name City/State/ Providence Phone Supervisor Type of Nursing Charge Experience Position Held/Specialty Shift Type of Nursing Primary Team Modified Primary Modified Team Other Patient Population From To Reason for Leaving Nurse/Patient Ratio May we contact your previous supervisor for a reference? Was this a Travel Assignment? With Which Agency? 2 of 15 PREVIOUS EMPLOYMENT 2 Facility Name City/State/ Providence Phone Supervisor Type of Nursing Charge Experience Position Held/Specialty Shift Type of Nursing Primary Team Modified Primary Modified Team Other Patient Population From To Reason for Leaving Nurse/Patient Ratio May we contact your previous supervisor for a reference? Was this a Travel Assignment? PREVIOUS EMPLOYMENT 3 Facility Name City/State/ Providence With Which Agency? Phone Supervisor Type of Nursing Charge Experience Position Held/Specialty Shift Type of Nursing Primary Team Modified Primary Modified Team Other Patient Population From To Reason for Leaving Nurse/Patient Ratio May we contact your previous supervisor for a reference? Was this a Travel Assignment? PREVIOUS EMPLOYMENT 4 Facility Name City/State/ Providence With Which Agency? Phone Supervisor Type of Nursing Charge Experience Position Held/Specialty Shift Type of Nursing Primary Team Modified Primary Modified Team Other Patient Population From To Reason for Leaving Nurse/Patient Ratio May we contact your previous supervisor for a reference? Was this a Travel Assignment? With Which Agency? 3 of 15 Please mark your level of experience 1. No theory and/or experience 2. Limited experience/need supervision and/or support 3. Experienced/minimal support needed to perform 4. Proficient/can perform independently EMR Cerner EPIC Eclipsys McKessson Meditech Allscripts Other Computerized System Computerized Physician Order Entry Bar Coding Medication Administration Other List: EMR Conversion Yes No ADDITIONAL INFORMATION Please list any additional education, skills, experience or other relevant qualifications in the space below. If more space is necessary, please print on a separate sheet and attach to the application? RESUME Please send a resume if you have one available. I am attaching a resume Yes No How did you discover MedCall NorthWest Inc.? Advertisement? Web Site Search? Referral by Hospital? Other? Referral by Individual? Referred by (please list first & last name): EMERGENCY TIFICATION In case of an emergency, please notify: FIRST CHOICE: Name: Address: Relationship: City: State/Province: Zip Code: Home Phone: Business Phone: Cell Phone: In case of an emergency, please notify: SECOND CHOICE: Name: Address: Relationship: City: State/Province: Zip Code: Home Phone: Business Phone: Cell Phone: 4 of 15 DISCLAIMER AND SIGNATURE The statements made in this application are true to the best of my knowledge. I understand that any omission or falsification will be the basis for disqualification of employment or termination of services. I authorize MedCall NorthWest to verify the information I have provided and to contact current and past employers and references concerning my ability, character and employment record. I release all such persons from liability for furnishing said information. I authorize MedCall NorthWest as my employer, to release any information that may be relevant to my employment to their client hospitals. MedCall NorthWest fully investigates all employees and applicants for employment in regard to references, all previous employment, state license status (including multiple states), drug screen (initial, for cause and random), and alcohol screening (for cause). MedCall requires a clear state criminal background check for all states where licenses are held. Positive pre-employment toxicology screens elicit/illegal drugs are basis for disqualification for employment or termination. Results of toxicology screens are reported to the appropriate authorities in accordance with WAC Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between MedCall NorthWest and the applicant for either employment or for providing of any benefit. All offers of employment are made conditional upon the applicant s proving employment authorization and identity in accordance with the Immigration Reform and Control Act of I have full knowledge and understand that my background and current status will be examined as outlined above, and give my permission for such inquiries. I understand that if I am hired by MedCall NorthWest, this information, along with skills checklist, licenses, certifications, drug screens, background checks, performance evaluations, cards, and employee health lab work will be released to MedCall NorthWest Client Hospitals for employment purposes. I give permission and release MedCall NorthWest from liability pertaining to releasing, and transmission of the information above for employment purposes while employed by MedCall NorthWest Inc. ELECTRONIC SIGNATURE Please enter your full legal name as it appears on your Social Security Card. First Name* Middle Name * Last Name* Last 4 of Social Security Number * Date * (mm/dd/yyyy) * Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement 5 of 15 Thank you for your interest in MedCall! We are excited about the opportunity to work with you! This document provides you a list of documents required by Medcall that must be submitted before we send you out on your first assignment. 1) Skills Checklists- specific to unit in which you will be working 2) Certifications- Front and Back copies of all required resuscitation credentials. 3) RN License- Please a list of all active and inactive state licenses you hold. 4) References/Evaluations-Three Evaluations from a Supervisor; must attest to your clinical abilities within the past 2 years 5) Competency Exam(s): a) Competency Test (attached to this application packet) b) Medication Test 6) Immunization History/Records: a) TB, Chest X-Ray and/or TB Questionnaire (1) Negative TB screen within one year; or, (2) If history of positive results, a Chest X-ray (dated after positive TB) as well as annual TB questionnaire is required. b) Mumps/Rubeola / Rubella (1) Positive titers or proof of MMR vaccine c) Varicella Positive titer or proof of Varicella vaccine. d) Hepatitis B: (1) Positive titer, or (2) Proof of series of 3 vaccines, or (3) Signed declination document. e) Tdap/Tetanus- proof of tetanus shot within 10 years or signed declination document. f) Medical Release/Statement of Health (Fill out and signed by a Physician, ARNP/NP, PA) g) Respiratory Fit Test 7) New Hire Initial Drug Screen- After we receive all the employment paperwork we will set up a time for you to take a New Hire Drug Screen. Our Drug Screening facilities are conveniently located throughout the Washington, Oregon, and Idaho. 8) Additional Documents: a) I-9 Form/Verification of Employment Form: i) Clear copies of your Social Security Card, and Drivers License, or ii) Passport, or iii) Work Visa/ Work Permits How you can submit these documents! Drop off: Our office is located at 201 N. Edison St #245, Kennewick, WA Mail: PO BOX 6507 Kennewick, WA Fax: , or local fax of 15 MEDICAL RELEASE Applicant Name Position Based on qualifications presented on your application form and/or in your job interview, you are hereby, offered a job with our organization conditional upon submitting to our standard medical review and the verification of your answers to the following questions. Your job offer cannot and will not be rescinded unless a medical review reveals that you cannot perform the essential functions of the job (with accommodations if requested), or you present a hazard to yourself or others. False or misleading statements are also grounds for rescinding this offer. This form must be accurate and complete for us to process. This information is considered personal and medical in nature and will be treated as such by handling it confidentially in strict compliance with the American with Disabilities Act. TO BE FILLED IN BY EXAMINING PHYSICIAN DATE OF EXAMINATION: DATE OF BIRTH: Please explain any physical, medical, or psychological conditions that would require accommodations to perform, or prevent from performing job requirements: PHYSICIAN S STATEMENT I have examined the individual named above, and to the best of my knowledge, he/she is in good physical and mental health, free of any communicable diseases, and is able to perform in his/her profession at full capacity. General Comments: Signature of Physician: Date: Printed Name of Physician: Address: City: State: Zip: Phone: Fax: 7 of 15 ANNUAL FIT MASK TEST/FIT TEST QUESTIONNAIRE Employee Name: Date: Licensure: Specialty: Mask Size: (Small/Med/Large/XL) Mask Type: (Make and Type) Please read all questions and answer accurately. 1. Have you had any significant weight loss over the last year? Yes No 2. Have you had any significant weight gain over the last year? Yes No 3. Have you grown any facial hair since your last fit test? Yes No 4. Have you had any facial procedures within the last year? Yes No 5. Are there any other incidents/events that would cause you to feel your fit mask size may have changed? Yes No 6. I have been informed of the policy regarding the use of the respirator. Yes No Comments: ELECTRONIC SIGNATURE Please enter your full legal name as it appears on your Social Security Card. First Name* Middle Name * Last Name* Last 4 of Social Security Number * Date * (mm/dd/yyyy) * Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement Spoke with employee via phone: If by phone: Agency Signature: Date: 8 of 15 HEPATITIS B: A MAJOR HAZARD HEPATITIS B VACCINATION INFORMATION SHEET Hepatitis B is an infection of the liver caused by the Hepatitis B virus. The virus is found in blood and other body fluids. Hepatitis B can disable a person for weeks or months and lead to complications. Some people who get infected with the Hepatitis B virus become chronic carriers capable of spreading the disease to others. This group usually has the greatest potential for developing long-term complications, such as chronic active hepatitis, chronic persistent hepatitis, cirrhosis, and primary cancer of the liver. UNDERSTANDING HEPATITIS B: THE COURSE IT TAKES Hepatitis B is far more contagious than AIDS. There is a greater chance of contracting Hepatitis B from needle sticks (up to 30 times greater), and it can live longer outside the body than the AIDS virus. While both viruses are found in blood, Hepatitis B is more concentrated in blood than AIDS. Hepatitis B is spread primarily through blood and body fluids that contain blood. In the workplace, the disease can be contracted through needle sticks or other punctures, through open wounds, or breaks in the skin, or through splashes of body fluids to mucous membranes. Health care workers, especially those who are exposed to blood frequently, are at significantly greater risk of acquiring Hepatitis B than the general population. CHOOSE TO BE VACCINATED Recombivax HB is a safe and effective vaccine used to prevent Hepatitis B. Recombivax HB is a noninfectious viral vaccine produced in yeast cells. Recombivax is not manufactured from any blood products. There have been no documented causes of anyone acquiring Hepatitis B from the vaccine. As with any vaccine or other medications, you could experience some side effects. The most common is a local reaction at the injection site. Recombivax is a series of three injections given in the muscle of the upper arm. Some people have reported soreness, redness, and swelling at the site of injection. Some people have also experienced one or more of the following flu-like symptoms: headache, fever, chills, fatigue, achiness, nausea, abdominal cramping and diarrhea. Women: Because pregnancy risks are unknown, vaccination of pregnant employees should be determined only on the advice of the employee s personal physician. If a pregnant employee chooses to be vaccinated, the child s father must also give consent. Recombivax HB consists of three doses of vaccine given according to the following schedule: 1st Dose: 2nd Dose: 3rd Dose: At Elected Date 1 Month Later 6 Months after 1st Dose The Centers for Disease Control recommends that anyone who has routine contact with blood or body fluids should be vaccinated. 9 of 15 HEPATITIS B FORM PROFESSIONAL MEDICAL SETTINGS: As an employee having occupational exposure to potentially infectious materials, you may receive the Hepatitis B vaccination series, free of cost to you. Please read the Hepatitis B Vaccination Information Sheet and complete this form by checking the box preceding the appropriate statement and signing, dating and indicating your Social Security Number at the bottom. CONSENT: As a healthcare professional having occupational exposure to blood or other potentially infectious materials, which includes the risk of acquiring Hepatitis B virus (HBV) infection, I have been informed about and offered the opportunity to receive the Hepatitis B vaccine (to be paid for by my current employer). I understand that I must have 3 doses of vaccine to develop immunity. However, as with any medical treatment, there is no guarantee that I will become immune or that I will not experience any adverse side effect from the vaccine. I accept the offer at this time. DECLINATION (GENERAL): I understand that due to my occupational exposure of blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HIV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination to this time. I understand that by declining this vaccine, continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future while actively working with MedCall NorthWest, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive it at no charge to me. DECLINATION (SPECIFIC): I am declining the opportunity to receive the Hepatitis B vaccination Series for the following reasons: (Please check one.) I have previously received the complete Hepatitis B vaccination series. (Please complete the Vaccination Record information below.) Antibody testing has revealed I am immune to Hepatitis B. (Date Tested:.) The vaccine is contraindicated for medical reason, describe_ Other: Explain ELECTRONIC SIGNATURE Please enter your full legal name as it appears on your Social Security Card. First Name* Middle Name * Last Name* Last 4 of Social Security Number * Date * (mm/dd/yyyy) * Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement 10 of 15 ANNUAL TUBERCULOSIS SURVEILLANCE FORM Name: 1. Date of your last TB skin test 2. Date of your last chest x-ray 3. Were the results within normal limits? a. Are you a known positive reactor to the tuberculin TB skin test? b. Have you had the BCG? c. Have you ever received treatment for the tuberculosis bacillus? d. Have you encountered an exposure to tuberculosis within the past year? e. Are you experiencing any of the following signs or symptoms that would be consistent with a diagnosis of tuberculosis? Night sweats Unexplained weight loss Bloody Sputum Fever Lingering Upper Respiratory Infection Please explain any Yes Statements: ELECTRONIC SIGNATURE Please enter your full legal name as it appears on your Social Security Card. First Name* Middle Name * Last Name* Last 4 of Social Security Number * Date * (mm/dd/yyyy) * Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement 11 of 15 VARICELLA STATMENT I,, have had the chicken pox as a child. ELECTRONIC SIGNATURE Please enter your full legal name as it appears on your Social Security Card. First Name* Middle Name * Last Name* Last 4 of Social Security Number * Date * (mm/dd/yyyy) * Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on this document, you are signing the Document electronically. You agree your electronic signature is the legal equivalent of your manual signature on the Agreement 12 of 15 REFERENCE FORM Applicant: Please ask your reference to complete this form. Thank You. APPLICANT: PLEASE COMPLETE THIS TOP SECTION APPLICANT NAME SOCIAL SECURITY NUMBER NAME OF REFERENCE TITLE INSTITUTION ADDRESS STATE/ZIP TELEPHONE I AUTHORIZE MEDCALL RTHWEST, INC. TO CONTACT CURRENT AND PAST EMPLOYERS AND REFERENCES CONCERNING MY ABILITIES, CHARACTER AND EMPLOYMENT RECORD. I RELEASE ALL SUCH PERSONS FROM LIABILITY FOR FURNISHING SAID INFORMATION. I AUTHORIZE MEDCALL RTHWEST AS MY EMPLOYER, TO RELEASE ANY INFORMATION THAT MAY BE RELEVANT TO MY EMPLOYMENT TO THEIR CLIENT HOSPITALS. APPLICANT S SIGNATURE/AUTHORIZATION: DATE PLEASE TE: The above person has applied to MedCall NorthWest for employment in the healthcare field and has submitted your name as a reference. We would appreciate your cooperation in responding to the following questions. Your responses will remain confiden
Search
Similar documents
View more...
Related Search
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks