Potential Strike
New Jersey
submit request
Emergency Dept. Trauma - RN
Requirements
:
BLS
ACLS
PALS
NIHSS
TNCC (preferred)
-- please complete this form honestly and accurately --
First Name
*
Last Name
*
Email
*
Phone
*
Do you have an active New Jersey or Multistate Compact RN license?
*
No
Yes
List your State and RN license number:
*
RN license expiration date:
*
Do you have BLS certification?
*
No
Yes
Do you have ACLS certification?
*
No
Yes
Do you have PALS certification?
*
No
Yes
Do you have NIHSS certification?
*
No
Yes
Do you have TNCC 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
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 ER experience do you have?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
How much, if any, PEDS ER experience do you have?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
Have you worked in the ER in the past year?
*
No
Yes
What Facility and City, State have you worked ER at most recently?
*
What level ER are you the most comfortable in? (Level 1 is the highest)
*
Level 1
Level 2
Level 3
Have you worked in an ER trauma room?
*
No
Yes
Do you have burn experience?
*
No
Yes
Can you start an IV?
*
No
Yes
Can you work in Triage or Fast track?
*
No
Yes
Can you transport via ambulance?
*
No
Yes
Can you transport via helicopter?
*
No
Yes
How much experience do you have as a Flight Nurse?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
Can you transport NICU/PICU?
No
Yes
Can you transport patients on ECMO?
No
Yes
Can you transport patients on VAD?
No
Yes
Can you transport patients on Vents?
No
Yes
Can you transport patients on Balloon Pumps?
No
Yes
Please supply an Emergency Contact name and phone number:
*
If the strike extends indefinitely, until what date can you work? (include any time off you require)
*
