Submit Request

First Name*

Last Name*

Email*

Phone*

Are you a registered dietitian?

No

Yes

What is your Dietitian registration number?*

Do you have a California state Dietitian certification? *

No

Yes

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 Dietitan?*

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

No

Yes

Do you have experience working as a dietician in an acute care/inpatient setting?*

No

Yes

What Facility have you worked as a Dietitian most recently?*

Are you well versed in developing methods for malnourishment and nutrition delivery?*

No

Yes

Do you have experience in tube nutrition?*

No

Yes

Are you experienced with Critical Care nutrition needs?*

No

Yes

Are you experienced with cancer center patients?*

No

Yes

Are you experienced with long term acute care?*

No

Yes

Are you experienced with pediatrics?*

No

Yes

Are you experienced with NICU?*

No

Yes

Are you able to independently assess clients’ nutritional and health needs?*

No

Yes

Do you have experience working in outpatient settings?*

No

Yes

Are you able to independently counsel clients on nutrition issues and healthy eating habits?*

No

Yes

Are you experienced in developing meal and nutrition plans?*

No

Yes

Are you experienced in evaluating and monitoring the effects of nutrition plans and practices?*

No

Yes

Are you able to independently document clients’ progress in the EMR?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential multi-state Strike

Submit Request

Dietitian