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First Name*

Last Name*

Email*

Phone*

Do you have an active California license?*

What is your California RN license number?*

License Expiration Date?*

Do you have BLS certification? *

No

Yes

Do you have an ACLS 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 age range of patients are you comfortable caring for?*

Do you have EP Lab experience?*

No

Yes

Can you scrub in and assist the Radiologist?*

No

Yes

Can you run the injector?*

No

Yes

How much recent experience do you have with IVUs?*

How much recent experience do you have with extremity cases?*

How much recent experience do you have with Impella Heart Pumps?*

How much recent experience do you have with balloon pumps?*

Can you set up and maintain a patient on a balloon pump?*

No

Yes

How much recent Neuro experience do you have?*

How much recent Vascular experience do you have?*

How much recent experience do you have inserting PICC lines?*

How much recent experience do you have with Watchman implant cases?*

Can you monitor/document?*

No

Yes

Can you assist with embolization and ablation cases? *

No

Yes

Do you have experience with conducting medicated stress tests? *

No

Yes

How much recent experience do you have assisting with T.E.E.?*

How much recent experience do you have performing NIPS? (Non-Invasive Program Stimulation testing)*

How much recent experience do you have with TAVRs?*

Please supply an Emergency Contact name and phone number:*

California Cath Lab/EP and

Interventional Radiology - RN