PRECISION HEALTHCARE STAFFING Please Fax to:

Transcription

1 PRECISION HEALTHCARE STAFFING Please Fax to: Employee Name: Time Time UNIT Reg. O.T. Day Date In Out worked Hours Hours SUN MON TUE WED THU FRI SAT Facility Name: Supervisor: Signature indicates acceptance of the client agreement on the bottom of this page and hours shown are true and correct. Client Signature: X X Total Straight Time Total Overtime hours min hours min Employee Signature: I understand that if my timecard is not faxed to PRECISION HEALTHCARE by noon on Monday my paycheck will be delayed. NO OVERTIME IS ALLOWED UNLESS APPROVED BY FACILITY AND PRECISION HEALTHCARE

2 EIN NUMBER Please call the IRS to obtain an EIN Number Or Name: Address: EIN Number: Signature:

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8 4209 Lakeland Drive, # 363 Phone Flowood, Ms Fax ( ) APPLICATION Please fill out application in its entirety Date Date available Phone : Shift desired ` Classification Precision Healthcare Staffing Name Address City State Zip Social Security # Date of Birth Citizenship Place of Birth Education Name and Address Yr. Graduated Type of Degree Nursing/Tech School University/ Other Nursing Applicants only: List specialties and years of experience Specialty: 1) Years Exp. Related Courses/Certification (i.e. Chemotherapy, EKG, Balloon, Pump, etc) All applicants: States licensed and license number 1) Professional License No. State Exp. Certification Date Received Expiration Date CPR ACLS PALS/ NALS BCLS Additional specialty courses taken: Course Date Work History: most recent job first Hospital/ Facility Address Specialty Dept./Unit/ Floor City/ State/ Province/ Zip Phone ( ) Date Employed: From To Number of Beds Hospital/ Facility Address Was this a travel assignment? Reason for Leaving Specialty Dept./Unit/ Floor City/ State/ Province/ Zip Phone ( ) Date Employed: From To Number of Beds Hospital/ Facility Address Was this a travel assignment? Reason for Leaving Specialty Dept./Unit/ Floor City/ State/ Province/ Zip Phone ( ) Date Employed: From To Number of Beds Hospital/ Facility Address Was this a travel assignment? Reason for Leaving Specialty Dept./Unit/ Floor City/ State/ Province/ Zip Phone ( ) Date Employed: From To Number of Beds Was this a travel assignment? Reason for Leaving

9 Are you elegible for rehire at all of your previous employment positions: Yes No If no, please attach sheet with explanation. Professional References: Must be knowledgeable of or have supervised your work performance Relation: Name: Phone: Address: City/State/Zip: Relation: Name: Phone: Address: City/State/Zip: Referred to Precision Healthcare Staffing by: Have you ever been convicted of a crime? Yes No If yes, please attach sheet with explanation. Has your nursing license ever been suspended or under investigation? Yes No If yes, please attach sheet with explanation. Have you ever terminated from a travel assignment? Yes No If yes, please attach sheet with explanation. Have you ever broken a travel contract? Yes No If yes, please attach sheet with explanation In case of an emergency, notify: Name Address City State Zip Phone ( ) I verify that the above information is true and correct. I understand that any misleading or incorrect statements may render application void. I hereby give on to all whom I have referenced to give a full accounting of my work performance and history. I do authorize the information of my previous, current and, future positions to be included in the agency s Quality Assurance Database and the use in QA activities. I understand that refusal by any party to provide said information may result in denial of offer of service. Signature Date

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11 Certified Nurse Assistant Skills Checklist Please indicate all areas that you have had actual work experience in. Your check mark in these areas indicates that you are proficient in performing these tasks. Level of proficiency: A- Never Performed. You have never performed the stated task and Date Social Security # have no experience with this type of skill. B- Familiar with. You are familiar with the stated task; but you would need more experience and practice to feel comfortable C- Experience in. You have performed this task several times; you Name feel moderately comfortable functioning independently. Signature D- Expert. You have performed this task frequently, you feel comfortable and proficient in this skill. Tasks A B C D Where Performed Tasks A B C D Where Performed VITAL SIGNS Elastic Stockings Temperature MEDICATIONS Pulse Assist Respiratory Supervise/ Remind Blood Pressure Weight Patient Kitchen HOME MANAGEMENT Bed Bath Tub Bath Shower Skin Care/ Oral Care Linen Change Laundry Bathroom/ Bedroom Grocery Shopping Shave/ Shampoo Foot Care/ Nail Care Dress (assist with) Transport Client Pediatrics Work Areas Ambulation Transfers/ ROM Assist to BSC/ Toilet Bedpan Catheter Care Incontinent Care Ostemy Care Record I&O Psychiatric Patients Oncology Patients Isolation Burn HIV CVA (Stroke Patients) Orthopedics Respiratory Meal Planning/ Diets Meal Preparation Maintain/ Clean Equipment Oral Suction

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