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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

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 experience Pre Admission Testing do you have?*

Have you worked Pre Admission Testing in the past year?*

No

Yes

What Facility have you worked Pre Admission Testing at most recently?*

Can you draw blood? *

No

Yes

Can you perform and interpret a 12 lead EKG?*

No

Yes

Do you have experience inserting PICC lines? *

No

Yes

If yes, what ages can you insert PICC lines?*

How much phone triage experience do you have?*

Do you have experience with surgical scheduling systems?*

No

Yes

Can you start an IV?*

No

Yes

What other specialty can you work? *

Please supply an Emergency Contact name and phone number:*

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

New Jersey - Potential Strike

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