Potential Strike - Washington
Submit Request
PICC Line - RN
Requirements
:
Washington state RN license or multistate compact
BLS
PICC Line certification (preferred)
-- please complete this submission form honestly and accurately --
First Name
*
Last Name
*
Email
*
Phone
*
Do you have an active Washington state RN license?
*
If Yes, what is your Washington state RN license number?
If No, what is your compact state and RN license number?
RN License Expiration Date:
*
Do you have BLS certification?
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No
Yes
Do you have ACLS certification?
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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?
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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?
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No
Yes
What is your Primary Shift preference?
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Day
Mid
Night
100% Flexible
How many years PICC line 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
Have you worked PICC line in the past year?
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No
Yes
What Facility have you worked at most recently?
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Can you insert PICC lines in adults?
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Yes
No
Can you insert PICC lines in children / neonates?
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Yes
No
Which brands are you experienced with?
Do you use x-ray, ultrasound or EKG to confirm placement?
Are you able to place mid lines?
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No
Yes
Are you comfortable inserting PICC lines independently without supervision?
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Yes
No
How much recent EPIC 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
Please supply an Emergency Contact name and phone number:
*
