Potential Strike
New Jersey
submit request
IMC Renal/Peritoneal Dialysis - RN
Requirements
:
BLS
ACLS
NIHSS (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?*
*
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 NIHSS 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?
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No
Yes
Can you work a Mid shift?
*
No
Yes
Can you work a Night shift?
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No
Yes
What is your Primary Shift preference?
*
Day
Mid
Night
100% Flexible
How many years Intermediate Care experience do you have?
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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 Intermediate Care in the past year?
*
No
Yes
What Facility have you worked Intermediate Care most recently?
*
What type of unit do you typically work in?
MS
MS Tele
Tele
Stepdown
PCU
IMC
Can you care for maintenance drips?
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No
Yes
If yes, which maintenance drips?
Can you titrate drips?
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No
Yes
If yes, which drips can you titrate?
Can you take care of post Cath patients?
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No
Yes
If yes, can you pull an arterial sheath?
No
Yes
If yes, Can you manage a TR band?
No
Yes
How much experience do you have with post open heart patients?
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None
Minimal
Regularly
Daily
Can you care for a patient with a chest tube?
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No
Yes
Can you care for a patient with Pacer Wires?
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No
Yes
Do you have experience in oncology?
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No
Yes
If yes, can you infuse chemo?
No
Yes
If yes, are you chemo certified?
No
Yes
Do you access ports?
*
No
Yes
Do you have experience in Neuro?
*
No
Yes
If yes, Have you cared for patients after brain surgery?
No
Yes
Do you have experience taking care of Stroke patients?
*
No
Yes
Do you have Burn experience?
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No
Yes
If yes, can you calculate total body surface area?
No
Yes
If yes, can you utilize the rule of 9?
No
Yes
Can you calculate fluid replacement?
No
Yes
Are you comfortable doing burn wound dressing changes?
No
Yes
How much recent wound care 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
Do you have experience in Renal?
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No
Yes
Can you perform Peritoneal Dialysis?
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No
Yes
When was the last time you performed Peritoneal Dialysis, if ever, and what type?
*
Do you have experience in Ortho?
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No
Yes
Do you have experience in Transplant?
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No
Yes
If yes, which types of transplants?
Do you have experience in Rehab?
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No
Yes
If yes, can you perform FIM scoring?
No
Yes
Do you have experience in Bariatrics?
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No
Yes
Can you care for a patient on bipap or chronic vent?
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No
Yes
Do you have experience with radial bands?
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No
Yes
Do you have gynecology experience?
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No
Yes
Can you care for post-op plastic surgery patients, and if yes, which cases?
*
Can you insert and troubleshoot PICC lines?
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No
Yes
Do you have Trauma experience?
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No
Yes
Can you start an IV?
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No
Yes
On a scale of 1 to 10, (10 being the highest) how confident are you interpreting rhythm strips?
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0
1
2
3
4
5
6
7
8
9
10
Can you pass a Tele test, if ordered?
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No
Yes
Are you comfortable with end-of-life care?
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No
Yes
Have you had death and dying training?
*
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)
*
