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First Name*

Last Name*

Email*

Phone*

Do you have California CPT I certification?*

No

Yes

What is your CPT I certification #?*

Do you have BLS certification? *

No

Yes

Do you have Phlebotomy 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

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 Phlebotomy experience do you have?*

Have you worked Phlebotomy in the past year?*

No

Yes

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

What age range can you draw blood from?*

How much experience do you have working in an inpatient hospital?*

How much experience do you have working in an outpatient area?*

How much experience do you have with drawing blood cultures?*

Have you worked in trauma cases?*

No

Yes

What is the order of draw?*

How much experience do you have with Centrifugation?*

How much experience do you have aliquoting Specimens?*

Are you able to perform Straight needle draws?*

No

Yes

Are you able to perform Micro-puncture draws?*

No

Yes

Are you competent in pediatric draws (0-18yrs)? *

No

Yes

How many years’ experience do you have drawing 0-1 year old patients?

Can you perform throat Culture Collections?*

No

Yes

Can you perform pediatric Heel Sticks?*

No

Yes

How much experience do you have with collecting MRSA/SANC specimens?*

Can you perform HPYLORI Breath Testing?*

No

Yes

Can you perform 12 lead EKG’s?*

No

Yes

Can you administer glucola for timed glucola testing?*

No

Yes

Can you apply a Holter Monitor to a patient?*

No

Yes

California - Potential Strike

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Phlebotomy Technician