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First Name*

Last Name*

Email Address*

Phone*

Do you have an active Pennsylvania or Compact RN license?*

No

Yes

Please list state and RN license number:*

RN license expiration date:*

Do you have an active BLS certification? *

No

Yes

Do you have an active ACLS certification?*

No

Yes

Do you have an active PALS certification? *

No

Yes

Do you have TNCC certification?*

No

Yes

Do you have an active NIHSS (stroke scale) 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

Do you have Charge RN experience within the last two years?*

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 much ICU experience do you have?

Have you worked ICU during the past year?*

No

Yes

What facility do you or did you last work ICU?*

How much recent CVICU experience do you have, if any?*

Can you take care of patients on CRRT or CVVH?*

No

Yes

If yes, what CRRT machines do you have experience with?

If yes, can you set up and take down and change the circuit for CRRT?

No

Yes

How much experience do you have with Balloon Pumps?*

Are you skilled with Tablo SLED (Nxstage) IABP and able to function independently?*

No

Yes

How much experience do you have with Impella?*

How much experience do you have with LVADs?*

If you have LVAD experience, what type?

When was the last time you recovered a fresh heart immediately from the OR?

Can you take care of a patient with an open chest?*

No

Yes

How much ECMO experience do you have?*

If you have ECMO experience, do you do VV and VA?

No

Yes

Can you take care of patients after transplants?*

No

Yes

If yes, what type of Transplants?

Do you have recent experience with Internal and External pacer wires?

Yes

No

Can you care for a Swan-Ganz catheter?

Yes

No

Can you infuse CHEMO?*

No

Yes

If yes, are you CHEMO Certified?

No

Yes

How much Burn ICU experience do you have?*

If burn experience, can you calculate total body surface area?

No

Yes

If burn experience, can you utilize the rule of 9?

No

Yes

If burn experience, can you calculate fluid replacement?

No

Yes

If burn experience, are you comfortable doing burn wound dressing changes?

No

Yes

Do you have wound vac experience?*

No

Yes

Do you have experience assisting with conscious sedation?*

No

Yes

How much Neuro ICU experience do you have?*

If Neuro experience, have you cared for patients after brain surgery?

No

Yes

Do you have experience administering TPA?*

No

Yes

Do you have experience with ICP monitoring?*

No

Yes

Do you have experience with bolts?*

No

Yes

Do you have current experience in Trauma ICU??*

No

Yes

How much recent experience do you have with Trauma Alerts?*

Can you pull an arterial sheath?*

No

Yes

Do you have procedural experience?*

Yes

No

Do you have experience with Meditech?*

No

Yes

What procedures are you comfortable assisting with?*

Please supply an Emergency Contact name and phone number:*

Potential Strike - Pennsylvania

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