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First Name*

Last Name*

Email*

Phone*

Do you have an active California RN license?*

No

Yes

What is your active RN license number?*

What is your RN license Expiration Date?*

Do you have BLS certification? *

No

Yes

Do you have a Wound Care (WOCN) 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 much recent Home Health experience do you have?*

Have you worked Home Health in the past year?*

No

Yes

At which Facility have you worked Home Health most recently?*

How much Hospice experience do you have?*

How much recent experience do you have with Oasis documentation?*

Can you admit patients to home care?*

No

Yes

Can you insert Foley?*

No

Yes

How much recent experience do you have with home care coding?*

How much recent experience do you have with trachs?*

How much recent experience do you have setting up a wound care vac or change container?*

Are you certified for Wound Care?*

No

Yes

Are you able to change the dressing on a wound care vac?*

No

Yes

Do you perform bladder irrigation?*

No

Yes

Do you have ostomy experience?*

No

Yes

Do you draw labs?*

No

Yes

Can you start an IV?*

No

Yes

Are you comfortable driving to home visits on your own?**

No

Yes

Are you comfortable using ride-share services (Uber, Lyft) for transportation to and from visits?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential Strike - multi-state

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