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First Name*

Last Name*

Email*

Phone*

Do you have an active California license?*

What is your California RN license #?*

RN License Expiration Date?*

Do you have BLS certification? *

No

Yes

Do you have NRP certification?*

No

Yes

Do you have FHM-Intermediate certification? *

No

Yes

Do you have FHM-Advanced certification?*

No

Yes

List any other certification you have:*

What specialties do you float to?*

Do you have the COVID Vaccination?*

No

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 Antepartum experience do you have?*

Have you worked Antepartum n the past year?*

No

Yes

What Facility have you worked Antepartum at most recently?*

How many years have you worked in couplet care?*

Have you cared for high risk moms post delivery?*

No

Yes

Are you a lactation nurse?*

No

Yes

If yes, are you lactation certified?*

No

Yes

Can you monitor fetal heart rhythms? *

No

Yes

Can you take care of antepartum?*

No

Yes

How much Labor and Delivery experience do you have ?*

How much NICU experience do you have ?*

If you have NICU experience, what level NICU?

Can you work independently in well baby nursery?*

No

Yes

Can you start an IV?*

No

Yes

Can you attend deliveries and do the initial assessments/admit?*

No

Yes

California - Potential Strike

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