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First Name*

Last Name*

Email*

Phone*

Do you have an NBSTSA-CST certification?*

No

Yes

Do you have BLS 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

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 experience do you have as an OR Tech?*

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

No

Yes

What Facility, city and state, have you worked as an OR Tech most recently?*

In which hospital units are you most comfortable working?*

What age range of patients are you comfortable caring for?*

How much recent Neuro experience do you have?*

How much recent Trauma experience do you have?*

Do you have inpatient or outpatient experience?*

Inpatient

Outpatient

Both

Do you scrub open-heart?*

No

Yes

Do you scrub CABG?*

No

Yes

Do you scrub triple-A?*

No

Yes

Do you scrub TAVR?*

No

Yes

Do you scrub heart and lung transplants?*

No

Yes

Do you assist with conscious sedation recovery?*

No

Yes

Describe any other duties you assist with or cases you typically scrub:*

What types/brands of equipment are you experienced with?*

Please supply an Emergency Contact name and phone number:*

Until what date can you work? (include the dates of any absences you may require)*

OR Neuro Tech