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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

Do you have ACLS certification?*

No

Yes

Do you have PALS certification?*

No

Yes

Do you have APHON 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

What ages are you comfortable with?*

Can you take care of adults?*

No

Yes

Can you work PICU or Peds step-down?*

No

Yes

Can you work NICU?*

No

Yes

Have you worked in Peds oncology?*

No

Yes

Are you able to administer chemotherapy in same-day surgery area?*

No

Yes

Do you have PACU experience?*

No

Yes

Are you able to administer medical infusions such as Remicade and Zoledronic acid?*

No

Yes

How much recent experience do you have with NAS (neonatal abstinence syndrome)?*

Are you comfortable caring for children on chronic vents?*

No

Yes

How much recent experience do you have with trachs?*

Can you start an IV?*

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)*

New Jersey - Potential Strike

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