Submit Request

First Name*

Last Name*

Email*

Phone*

List any certifications you have:*

What specialties do you float to?*

Do you have the COVID Vaccination?*

No - Requesting Exemption

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 of Customer Service do you have?*

Have you worked in Customer Service in the past year?*

No

Yes

How much computer experience do you have with data entry?*

Which software/EMR systems do you have experience with?*

Can you input admissions into the computer system?*

No

Yes

Are you comfortable using a paging system to coordinate staff for the unit RN?*

No

Yes

Are you able to compile paper charts?*

No

Yes

Are you proficient answering phones?*

No

Yes

Can you route mail and internal communications?*

No

Yes

Are you comfortable using copy machines, fax machines, and other office equipment?*

No

Yes

Do you have experience with general clerical duties, including labeling and filing documentation?*

No

Yes

Please supply an Emergency Contact name and phone number:*

NW - Potential Strike

Submit Request