Potential Strike - multi-state
Submit Request
RN - ICU
Requirements
:
BLS
ACLS
NIHSS (preferred)
-- please complete this submission form honestly and accurately --
First Name
*
Last Name
*
Email Address
*
Phone
*
In which region(s) would you prefer to be placed as an ICU RN?
*
California - Northern
California - Southern
Oregon
Washington
No Preference
List your active RN license NUMBER and STATE:
*
No
Yes
RN license expiration date:
*
Do you have BLS certification?
*
No
Yes
Do you have ACLS certification?
*
No
Yes
Do you have 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 Nurse Experience?
*
No
Yes
Can you work a Day shift?
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No
Yes
Can you work a Mid shift?
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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?
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None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
How much CVICU experience do you have?
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
Have you worked in the ICU during the past year?
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No
Yes
What facility do you or did you last work ICU?
*
What type of ICU unit do you typically work in?
*
Can you take care of patients on CRRT?
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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?
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None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
How much experience do you have with Impella?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
How much experience do you have with LVADs?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
If you have LVAD experience, what type?
How much ECMO experience do you have?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
If you have ECMO experience, do you do VV and VA?
No
Yes
Can you recover a fresh open heart patient immediately from OR?
*
No
Yes
Can you take care of patients after transplants?
*
No
Yes
If yes, what type of Transplants?
Can you infuse CHEMO?
*
No
Yes
If yes, are you CHEMO Certified?
No
Yes
How much Burn ICU experience do you have?
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None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
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
How much Impella experience do you have?
*
None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
Do you have experience assisting with conscious sedation?
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No
Yes
How much Neuro ICU experience do you have?
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None
6 Months or less
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
More than 10 Years
If Neuro experience, have you cared for patients after brain surgery?
No
Yes
Do you have experience with ICP (intra-cranial pressure monitoring)?
*
No
Yes
Do you have experience with bolts?
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No
Yes
Do you have current experience in Trauma ICU??
*
No
Yes
Can you pull an arterial sheath?
*
No
Yes
Please supply an Emergency Contact name and phone number:
*
