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First Name*

Last Name*

Email*

Phone*

Do you have an active Illinois RN license?*

No

Yes

RN license number:*

RN license expiration date:*

Do you have BLS certification? *

No

Yes

Do you have a Case Management or Utilization Review certifciation?*

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

Do you have Charge Nurse Experience?*

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 much recent Case Management experience do you have?*

At what facility have you worked Case Management most recently?*

How much recent utilization review experience do you have?*

List any specific specialties you have experience in:*

How much experience do you have with intraqual?*

Do you have recent ER case management experience?*

No

Yes

Do you have experience with IVF patients?*

No

Yes

Do you have experience discharging PEDS and NICU patients into home care?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential Strike - Illinois

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