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First Name*

Last Name*

Email*

Phone*

Do you have an active Illinois RN license?*

No

Yes

List your State and RN license number:*

RN license expiration date:*

Do you have BLS certification? *

No

Yes

Do you have PALS certification?*

No

Yes

Do you have a CNOR certification?*

No

Yes

Are you certified to First Assist (RNFA)?*

No

Yes

If yes, which cases do you First-Assist?

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 many years OR experience do you have?*

Have you worked OR in the past year?*

No

Yes

What Facility and City, state have you worked OR recently?*

Have you worked in an inpatient setting, outpatient setting, or both?*

Inpatient

Outpatient

Both

Do you scrub?*

No

Yes

Which cases do you scrub, if any?

What specialty/cases do you circulate most?*

Which eye cases can you circulate?*

Can you circulate and/or scrub in the open heart room?*

No

Yes

How much recent experience do you have in a PEDS OR?*

How much recent robotic experience do you have?*

Do you have any Davinci robotic experinece?*

No

Yes

Do you have any Mazur robotic experience?*

No

Yes

How much recent Neuro experience do you have?*

Can you circulate organ transplants?*

No

Yes

If yes, which transplant cases can your circulate?

How much recent Ortho experience do you have?*

Are you proficient in total joint and spine?*

No

Yes

How much experience do you have with organ or tissue harvest?*

Are you able to implement malignant hyperthermia protocols?*

No

Yes

How much Endo experience do you have?

Do you have current Trauma OR experience?*

No

Yes

Can you perform wound debridement?*

No

Yes

How much recent plastic surgery experience do you have?*

Which plastic surgery cases are you experienced with?*

Are you experienced with Otolaryngology cases?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential Strike - Illinois

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