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First Name*

Last Name*

Email*

Phone*

Do you have an active ARDMS?*

No

Yes

What is your ARDMS registration number?*

Do you have an active RDCS?*

Yes

No

Do you have an Oregon Sonography state license?:*

No

Yes

Please provide your Oregon state license # and expiration date:*

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 - 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 much recent experience do you have as an Echo Tech?*

Have you worked as an Echo Tech in the past year?*

No

Yes

What Facility have you worked as an Echo Tech most recently?*

What age patients do you care for?*

Can you perform cardiac echo?*

No

Yes

How much experience do you have performing 3-D echo? *

How much experience do you have performing TEE? *

Can you perform OB ultrasound?*

No

Yes

Can you utilize PACS (picture archiving and communications system) with accuracy?*

No

Yes

What specialty or hospital unit are you the most comfortable in?*

What types of ultrasound are you trained to perform?*

Please supply an Emergency Contact name and phone number:*

NW - Potential Strike

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