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First Name*

Last Name*

Email*

Phone*

Do you have an active California state Speech Language Pathology license?*

No

Yes

List your California SLP license number:

RN license expiration date:*

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 Speech Therapy experience do you have?*

Have you worked Speech Therapy in the past year?*

No

Yes

At which Facility have you worked Speech Therapy most recently?*

Have you worked in a hospital setting?*

No

Yes

Have you worked in an Inpatient/Outpatient setting?*

No

Yes

Have you worked in a School setting?*

No

Yes

Have you worked in a Skilled Nursing Facility setting?*

No

Yes

Have you worked in a Rehab setting?*

No

Yes

What age patients are you comfortable caring for?*

Describe your experience with Speech Therapy:*

Are you able to evaluate any speech, language, communication, or swallowing disorders?*

No

Yes

In what areas do you specialize?*

Can you perform fiberoptic scope swallow evaluations?*

No

Yes

Do you perform vital lead procedures?*

No

Yes

Can you manage work flow, answer phones, do med refills?*

No

Yes

Can you provide training and education to patients and their loved ones?*

No

Yes

Do you have NICU experience?*

No

Yes

Can you work EPIC in a basket?*

No

Yes

What charting software/brands do you have experience with?*

Please highlight any additional skills or unique experience you may have:

Please supply an emergency contact name and phone number:*

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Potential Strike - California

Submit Request