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First Name*

Last Name*

Email*

Phone*

Do you have an active California license?*

What is your California RN license #?*

License Expiration Date?*

Do you have BLS certification? *

No

Yes

Do you have ACLS 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 Radiation Oncology experience do you have?*

Have you worked Radiation Oncology in the past year?*

No

Yes

What Facility have you worked Radiation Oncology at most recently?*

Can you educate patients on Radiation?*

No

Yes

What scheduling systems have you used?*

What type of skin treatments do you have experience with?*

How much phone triage experience do you have?

Can you perform moderate sedation?*

No

Yes

Can you assist in positioning?*

No

Yes

Can you assist with mold making?*

No

Yes

Can you start an IV?*

No

Yes

What ages can you administer moderate sedation to?*

Have you received formal didactic and hands on training in providing moderate procedural sedation?*

No

Yes

Which sedation medications are you most comfortable using?*

How many years experience do you have in designating an ASA Physical Status Classification?*

How much recent experience do you have with Ketamine?

What procedures have you sedated for?*

Can you monitor End title CO2?*

No

Yes

Which department and/or setting have you sedated in?*

California - Potential Strike

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