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First Name*

Last Name*

Email*

Phone*

Do you have BLS 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 experience do you have?*

Have you worked this specialty in the past year?*

No

Yes

What Facility have you worked this specialty most recently?*

Is your experience inpatient or outpatient?*

What ages are you most comfortable caring for?*

Are you comfortable leading/monitoring group activities?*

Yes

No

Are you comfortable leading group therapy?*

Yes

No

Can you assist with ADLs? (personal grooming, bathing, toileting, feeding, oral hygiene?)*

Yes

No

Do you have knowledge of signs and symptoms of behavioral diagnosis and usual interventions?*

Yes

No

Can you assist with electroshock therapy?*

Yes

No

Do you have experience 1:1 with suicidal patients?*

Yes

No

Do you have experience observing and documenting for a patient in 5 point restraints?*

Yes

No

Are you comfortable documenting patients belongings upon admission?*

Yes

No

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Minnesota - Potential Strike

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