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First Name*

Last Name*

Email*

Phone*

Do you have BLS certification? *

No

Yes

List any other certification you have:*

What specialties do you float to?*

Do you have the COVID Vaccination?*

No - Requesting Exemption

Yes - Vaccinated

Yes - Vaccinated with Booster

Typically for strike assignments: 5x12/hr shifts (60/hrs week) Are you ok with this?*

No

Yes

Can you work a Day shift?*

No

Yes

Can you work a Mid shift?*

No

Yes

Can you work a Night shift?*

No

Yes

What is your Primary Shift preference?*

Day

Mid

Night

100% Flexible

How many years experience do you have as a Clerk?*

Have you worked as a Clerk in the past year?*

No

Yes

What Facility have you worked as Clerk most recently?*

How much recent experience do you have Clerking in an acute care or inpatient setting, if any?*

How much recent experience do you have as a Laboratory Clerk, if any?*

Which software/EMR systems do you have experience with?*

Can you input admissions into the computer system?*

No

Yes

Are you comfortable using a paging system to coordinate staff for the unit RN?*

No

Yes

Are you able to compile paper charts?*

No

Yes

Are you proficient answering phones?*

No

Yes

Can you route mail and internal communications?*

No

Yes

Are you comfortable using copy machines, fax machines, and other office equipment?*

No

Yes

Do you have experience with general clerical duties, including labeling and filing documentation?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential Multi-state Strike

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