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First Name*

Last Name*

Email*

Phone*

Do you have an active Oregon state RN license?*

What is your Oregon state RN license number?*

RN license expiration date?*

Do you have BLS certification? *

No

Yes

Do you have ACLS certification?*

No

Yes

Do you have WOCN wound care 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 MS TELE experience do you have?*

Have you worked MS TELE in the past year?*

No

Yes

What Facility have you worked MS TELE most recently?*

Can you care for maintenance drips? *

No

Yes

If yes, which maintenance drips?

Can you titrate drips? *

No

Yes

If yes, which drips can you titrate?

Can you take care of post Cath patients? *

No

Yes

If yes, can you pull an arterial sheath?

No

Yes

If yes, Can you manage a TR band?

No

Yes

How much experience do you have with post open heart patients?*

Can you care for a patient with a chest tube?*

No

Yes

Can you care for a patient with Pacer Wires?*

No

Yes

Do you have experience in oncology? *

No

Yes

If yes, can you infuse chemo?

No

Yes

If yes, are you chemo certified?

No

Yes

Do you access ports?*

No

Yes

Do you have experience in Neuro? *

No

Yes

If yes, Have you cared for patients after brain surgery?

No

Yes

Do you have experience taking care of Stroke patients?*

No

Yes

Do you have Burn experience? *

No

Yes

If yes, can you calculate total body surface area?

No

Yes

If yes, can you utilize the rule of 9?

No

Yes

Can you calculate fluid replacement?

No

Yes

Are you comfortable doing burn wound dressing changes?

No

Yes

How much recent wound care experience do you have?*

Do you have experience in Renal? *

No

Yes

Can you perform peritoneal dialysis?*

No

Yes

Do you have experience in Ortho?*

No

Yes

Do you have experience in Transplant? *

No

Yes

If yes, which types of transplants?

Do you have experience in Rehab?*

No

Yes

If yes, can you perform FIM scoring?

No

Yes

Do you have experience in Bariatrics?*

No

Yes

Can you care for a patient on bipap or chronic vent?*

No

Yes

Do you have experience with radial bands?*

No

Yes

Do you have gynecology experience?*

No

Yes

Can you care for post-op plastic surgery patients, and if yes, which cases?*

Can you insert PICC lines?*

No

Yes

Can you troubleshoot PICC lines?*

No

Yes

What age range of patients are you comfortable providing wound care? *

How much recent experience do you have with wound care debridement?*

How much recent experience do you have with wound wrapping?*

How much recent experience do you have with biological grafting?*

How much recent experience do you have with hyperbaric oxygen treatments?*

Briefly detail your role in any hyperbaric oxygen treatment (if applicable):

Are you able to set up a wound care vac and change the drainage container?*

No

Yes

If yes, are you able to change the dressing on a wound care vac?

No

Yes

Please supply an Emergency Contact name and phone number: *

Oregon - Potential Strike

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