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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 NIHSS certification?*

No

Yes

Do you have CRN or RNCB 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 IR experience do you have?*

Have you worked IR in the past year?*

No

Yes

What Facility and City, state have you worked IR most recently?*

Can you scrub in and assist the radiologist?*

No

Yes

How much recent neuro experience do you have?*

Can you run the injector?*

No

Yes

Do you do Neuro cases?*

No

Yes

Do you do Vascular cases?*

No

Yes

How much recent experience do you have with procedures using EKOS? (Ekosonic Endovascular System)*

Can you initiate Angio Vac ?*

No

Yes

If yes, how much recent experience do you have with Angio Vac procedures?

How much recent experience do you have assisting with chemo administration?*

How much recent experience do you have in ablation cases?*

How much recent experience do you have in radio frequency procedures, thrombolytics?*

How much recent experience do you have with embolization procedures?*

Have you administered embospheres?*

No

Yes

Can you start an IV?*

No

Yes

Do you have experience assisting with conscious sedation?*

Yes

No

What ages can you administer moderate sedation to?*

Do you have any experience inserting PICC Lines?*

Yes

No

If yes, what ages?

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)*

Interventional Radiology - RN