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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 an PALS 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

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

Do you scrub?*

No

Yes

How much recent experience do you have working in an EP lab?*

How much recent experience do you have with IVUs?*

How much recent experience do you have with extremity cases?*

How much recent experience do you have with Impella Heart Pumps?*

How much recent experience do you have with balloon pumps?*

Can you set up and maintain a patient on a balloon pump?*

No

Yes

How much recent experience do you have in Watchman Implant cases?*

Can you monitor/document?*

No

Yes

Can you pull an arterial sheath?*

No

Yes

Can you circulate?*

No

Yes

Do you have experience with operating EKG machines? *

No

Yes

Do you have experience with conducting medicated stress tests? *

No

Yes

How much recent experience do you have assisting with T.E.E.?*

How much recent experience do you have performing NIPS? (Non-Invasive Program Stimulation testing)*

How much recent experience do you have with TAVRs?*

Do you Scrub? *

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential Strike - Illinois

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