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First Name*

Last Name*

Email*

Phone*

In what state(s) do you hold an active LPN/LVN license?*

What is your active LPN/LVN license number?*

Do you hold an active multistate compact LPN/LVN license, and if yes, in which state?*

Do you have BLS certification? *

No

Yes

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 an LPN/LVN?*

Have you worked as a LPN/LVN in the past year?*

No

Yes

At what facility have you worked as an LPN/LVN most recently?*

How much experience do you have in a hospital setting?*

What hospital settings have you worked?*

Do you have Home Health experience?*

No

Yes

If YES, how much Home Health experience do you have?

Have you worked in any other settings or modalities? *

No

Yes

If YES, what types of clinical settings have you worked?

Can you perform EKGs?*

No

Yes

Are you trained or certified to start an IV or hang IV meds?*

No

Yes

Can you draw labs?*

No

Yes

Do you have 1:1 experience with disoriented or suicidal patients?*

No

Yes

Do you have inpatient experience, outpatient experience, or both?*

Inpatient

Outpatient

Both

Can you interpret tele strips?*

No

Yes

List any other skills or duties you can perform:*

Please supply an Emergency Contact name and phone number:*

Potential Strike - Multi-state

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