Basic Information

Full Legal Name - Along with Middle Name

Phone Number (Mobile/Home)

Primary Email ID

Current Location

Work Authorization (Green Card or Citizen)

Date of birth: MM/DD/YY

SSN: (last four digits) (Full SSN might be required depending on need of the clients)

Professional Information/Preferences

Are you currently on Assignment? (Y/N) If, is it full-time or a contract

Is it Full Time or Contract?

How many days Notice period required to serve if working permanent?

Current Contract End Date

When are you looking to start the next assignment?

Are you requesting any time off during the next 13 weeks assignment? (Any RTO not mentioned will not be approved and this can lead to cancelation of the assignment)

Shift interested in: (Nights/Days/Evenings)

Are you open for any other shift apart from mentioned above

Shift hours interested in 8/10/12 hours

Are you open for any other shift hours apart from mentioned above

Preferred Time for the phone interview:

Higehst Patient ratio:

Trauma level worked in (I, II, III, IV)

EMR Charting system:

Equipment/Tools/Machines used (For Lab/Imaging Professionals)

Please share recent and updated resume

Education Information

Highest related Completed Education (Please do not mention the ongoing education)

College/University Name

Please attach copy of Transcript/Degree/Diploma

Certifications and Licenses

Active License & Number (State license name)

BLS

ACLS

PALS

NRP

TNCC/AWHONN/ENPC/Any other speciality Certification

CST/Sterile/ARDMS/ARRT/ASCP/CMA /Any other professional Certification

Travel Information

How are you going to travel to the facility? (Car/Flight)

Are you travelling alone for the assignment?

Do you have sufficient Funds to manage the expenses for your travel/stay for the first week of the contract?

2 Professional references within last 1 year

Name of Supervisor

Facility worked with

Title

Email ID

Phone Number

2nd Reference

Name of Supervisor

Facility worked with

Title

Email ID

Phone Number

Immunizations

Do you have all shots for Covid including boosters?

Have you already taken your Flu shot

MMR

Vericella

Physical

Fit Test

TDAP

TB/TSPOT/TB-gold/Q-gold

SSN Card (after the offer)

DL (After the offer)