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First Name*

Last Name*

Email*

Phone*

Do you have an active Michigan RN license?*

No

Yes

If NO, which state issued your RN license?

RN License number:*

RN License Expiration Date:*

Do you have BLS certification? *

No

Yes

Do you have NRP 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 experience Postpartum Mom Baby do you have?*

Have you worked Post Partum Mom Baby in the past year?*

No

Yes

What Facility and City, state have you worked Post Partum Mom Baby 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

Can you titrate or manage a magnesium drip?*

No

Yes

Can you assist with circumcision?*

No

Yes

Can you perform infant blood testing?*

No

Yes

Can you perform state hearing test?*

No

Yes

How much Labor and Delivery experience do you have if any?*

How much NICU experience do you have if any? *

If you do have NICU experience, which level?

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

MICHIGAN - Potential Strike

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