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First Name*

Last Name*

Email Address*

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 NRP certification?

No

Yes

List any other certification you have:*

What other 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

What level NICU do you typically work in?*

What is the earliest gestation you can care for?*

How much recent experience do you have with Jets?*

How much recent experience do you have with oscillators?*

How much recent experience do you have with vents?*

How much recent experience do you have with Cpap?*

How much experience do you have caring for a neonate on ECMO?*

Are you comfortable with applying and caring for total body cooling and/or head cooling?*

No

Yes

Do you attend deliveries?*

No

Yes

Have you transported neonates outside the hospital?*

No

Yes

If yes, which mode?

Do you have charge nurse experience?*

No

Yes

Can you start an IV?*

No

Yes

Do you have experience with Nitric Oxide?*

No

Yes

Are you a lactation nurse?*

No

Yes

If yes, are you certified?

No

Yes

Do you care for post-surgical NICU patients?*

No

Yes

If yes, what surgeries?

Do you have any experience inserting PICC Lines?*

No

Yes

Do you have experience with umbilical lines?*

No

Yes

Are you familiar with Arctic Sun or Zoll brand therapeutic temperature control?*

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)*

NICU - RN