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First Name*

Last Name*

Email Address*

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 ACLS certification?*

No

Yes

Do you have PALS certification?*

No

Yes

Do you have NIHSS (stroke scale) certification?*

No

Yes

List any other certification you have:*

What other 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 ICU experience do you have?*

How much CVICU experience do you have?

Have you worked in the ICU during the past year?*

No

Yes

What facility do you or did you last work ICU?*

What type of ICU unit do you typically work in?*

Can you take care of patients on CRRT?*

No

Yes

If yes, what CRRT machines do you have experience with?

If yes, can you set up and take down and change the circuit for CRRT?

No

Yes

How much experience do you have with Balloon Pumps?*

How much experience do you have with Impella?*

How much experience do you have with LVADs?*

If you have LVAD experience, what type?

How much ECMO experience do you have?*

If you have ECMO experience, do you do VV and VA?

No

Yes

Can you recover a fresh open heart patient immediately from OR?*

No

Yes

Can you take care of patients after transplants?*

No

Yes

If yes, what type of Transplants?

Can you infuse CHEMO?*

No

Yes

If yes, are you CHEMO Certified?

No

Yes

How much Burn ICU experience do you have?*

If burn experience, can you calculate total body surface area?

No

Yes

If burn experience, can you utilize the rule of 9?

No

Yes

If burn experience, can you calculate fluid replacement?

No

Yes

If burn experience, are you comfortable doing burn wound dressing changes?

No

Yes

Do you have wound vac experience?*

No

Yes

How much Impella experience do you have?*

Do you have experience assisting with conscious sedation?*

No

Yes

How much Neuro ICU experience do you have?*

If Neuro experience, have you cared for patients after brain surgery?

No

Yes

Do you have experience with ICP (intra-cranial pressure monitoring)?*

No

Yes

Do you have experience with bolts?*

No

Yes

Do you have current experience in Trauma ICU?*

No

Yes

Can you pull an arterial sheath?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential Strike - Illinois

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