620 N. Trade Winds Parkway Suite A Columbia, MO 65202 Toll Free Phone & Fax 877.883.8677
Pre-Employment Check List
Please provide clear copies of the following along with your completed application. Please complete our application entirely, incomplete applications will delay
processing.
□ Drivers License □ Social Security Card □ Current Nursing License □ Any Certifications (if applicable) □ Current CPR □ Current ACLS (if applicable) Complete the following forms (included in this application packet).
□ Application □ Reference Check #1 □ Reference Check #2 □ Skills Checklist □ Testing as required □ Health Statement/Physical □ Proof of Vaccination History □ HIPAA Statement □ I-9 Documentation
Post Hire – Check List
□ Federal W-4 □ Missouri W-4 □ Direct Deposit Form □ Payroll Input Form
Thank You for applying with us. Please feel free to call us anytime if you have questions.
620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Name:
Please indicate 1, 2, 3, or 4 in boxes below using the following rankings: 1 = Clinicals Only 2 = Some Experience 3 = Experienced 4 = Can Perform Task Independently
UNIT / SKILLS Exp UNIT / SKILLS Exp
Premature/Newborn/Neonate (birth - 30 days) Young Adults (18 - 39)
Infant (30 days - 1 year) Middle Adults (39 - 64)
Toddler (1 - 3 years) Older Adults (64+)
Preschooler (3 - 5 years) Growth/Developmental Parameters
School Age (5 - 12 years) Family Intervention Skills
Adolescents (12 - 18 years) Death/Dying
NEUROLOGICAL SYSTEM
Assess sensory-motor function extremities Maintain cervical/spinal traction
Assess cranial nerves Use Glascow Coma scale
Assist with lumbar puncture Visual acuity measurement
Care of patients with:
Acute head injury Seizure disorder
Fresh CVA Fresh spinal cord injury
Impending D.T.'s Multi-system trauma
CV/CIRCULATORY
Arrest procedure initiation Defibrillation
*prep & administer meds *arterial line insertion
*family involvement during arrests *exterior pacemaker insertion
Assess heart sounds *Swan Ganz insertion Blood pressure monitoring Set up, run, interpret 12 lead EKG Cardioversion Use of cardiac monitor
Pulse oximetry Use of Doppler
Care of patients with: Fresh MI
Acute aneurysm Pulmonary edema Angina Shock Cardiac contusion *cardiogenic
CHF *hypovolemic
Deep vein thrombosis *septic
RESPIRATORY
Ambu bag techniques Obtain arterial blood gas
Administer oxygen *result interpretation Use of apnea monitor Suctioning Assess lung sounds *use of emergency equipment Assist in intubation/extubation Thoracentesis Chest tube insertion (assist in) Ventilator management Nebulizer set up and use Tracheostomy 1)
*trach tray set up 2)
*assist with emergency trach 3)
Care of patients with: Hemothorax
Acute respiratory distress Pneumonia
Collapsed lung Pulmonary embolism
SKILLS CHECKLIST EMERGENCY ROOM
620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
EMERGENCY ROOM SKILLS CHECKLIST (continued)
UNIT / SKILLS Exp UNIT / SKILLS Exp
GI/GU/REPRODUCTIVE ENDOCRINE Peritoneal lavage
Catheter insertion Poison control
*female Product of conception specimen
*male Rape crisis intervention
D&C procedure *GYN exam
NG tube insertion/lavage *legal ramification of rape exam
Care of patients with: GI bleed
Acute cholecystitis Hyper/hypoglycemia
Acute Renal Failure Multiple abdominal wounds
Appendicitis Pancreatitis
Bowel obstruction Spontaneous abortion
INTEGUMENTARY/ORTHOPEDIC Sizing crutches, teaching use
Cast (fiberglass/plaster) Splints
*application and education of *application of
Cervical, knee and shoulder immobilizers Suture/laceration repair
Care of patients with:
Amputated part Gun shots
Burns Stab wounds
IV THERAPY
Administration/mixing of Iv meds Insertion of central line
Administration of IV fluids *CVP tray set up
Autotransfusion Insertion of peripheral line
Blood/blood product administration Intraosseous infusion
*precautions Pump operations
Calculate doses *IVAC
Calculate rates *IMED
Hang IV piggybacks *Other:
MEDICATION ADMINISTRATION
Injections PO administration
*preparation of meds/syringe SL administration
*site selection (i.e. SQ vs IM)
Use of the following:
Amiodarone Isuprel Atropine Lidocaine Bicarbonate Mannitol Bretylium Morphine Cardizem Nipride Dextrose Nitroglycerin Digitalis Phenobarbital Dopamine Pavulon Epinephrine Pitressin Heparin Thromobolytic meds Insulin Verpamil
PSYCHIATRIC CONSIDERATIONS Psychiatric patient assessment Assessing for domestic violence *care of acute psychotic *child abuse/neglect *care of violent patient *spouse/partner battering *administration of psychiatric medication Monitor chronic alcoholic Use of restraints
620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
EMERGENCY ROOM SKILLS CHECKLIST (continued)
UNIT / SKILLS Exp UNIT / SKILLS Exp
ADDITIONAL NURSING RESPONSIBILITIES Ear irrigation
Specimen collection Eye irrigation
*capillary blood draw Universal isolation procedures/precautions
*sputum Lab value interpretation
*stool Organ procurement
*venipuncture/adult Postmortem procedure
*venipuncture/child Pre-op teaching
*wound culture Post-op teaching
Initial assessment/documentation Problem oriented medical charts
Charge nurse responsibilities Triage/RN role
Discharge planning/teaching Use of EMS system/radio
The information I have given is true and accurate to the best of my knowledge. I hereby authorize
Pulse Medical Staffing to release this Skills Checklist to facilities/clients of Pulse Medical Staffing in
relation to consideration of my Employment with those facilities/clients.
Signature:
Date:
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
PROFESSIONAL REFERENCE CHECK
I, _________________________________________________________
(Employee Name)
Authorize Pulse Medical Staffing to request any information concerning my qualifications, performance and work ethics. Further I hereby release the company or person completing this form from any and all liability in supplying the requested information.
Signature:
Date:
REFERENCE INFORMATION (Applicant, please complete)
Company: Reference Name:
Position Held: Reference Phone:
Start Date: Reference Address:
End Date: Reason for Leaving:
Applicant – DO NOT WRITE BELOW THIS LINE
---------------------------------------------------------------------------------------------------------------- Would you rehire this person? Yes No If no, please explain: ______________________________________________________________________ Please rate the applicant on a scale from 1 to 10 (10 being the highest):
Attribute/Quality 1 2 3 4 5 6 7 8 9 10 Additional Comments
Dependability
Flexibility
Team Work
Professionalism
Interaction with Co-Workers
Interaction with Supervisors
Joint Commission Compliance
HIPPA Compliance
Policies/Procedures
Appearance
What is your affiliation to the above applicant? Supervisor / Former Supervisor Coworker / Former Coworker
Human Resources Other: ___________________
Completed by:
Signature:
Date:
Title:
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
PROFESSIONAL REFERENCE CHECK
I, _________________________________________________________
(Employee Name)
Authorize Pulse Medical Staffing to request any information concerning my qualifications, performance and work ethics. Further I hereby release the company or person completing this form from any and all liability in supplying the requested information.
Signature:
Date:
REFERENCE INFORMATION (Applicant, please complete)
Company: Reference Name:
Position Held: Reference Phone:
Start Date: Reference Address:
End Date: Reason for Leaving:
Applicant – DO NOT WRITE BELOW THIS LINE
---------------------------------------------------------------------------------------------------------------- Would you rehire this person? Yes No If no, please explain: ______________________________________________________________________ Please rate the applicant on a scale from 1 to 10 (10 being the highest):
Attribute/Quality 1 2 3 4 5 6 7 8 9 10 Additional Comments
Dependability
Flexibility
Team Work
Professionalism
Interaction with Co-Workers
Interaction with Supervisors
Joint Commission Compliance
HIPPA Compliance
Policies/Procedures
Appearance
What is your affiliation to the above applicant? Supervisor / Former Supervisor Coworker / Former Coworker
Human Resources Other: ____________________
Completed by:
Signature:
Date:
Title:
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Employee Health Statement
Employee Name: __________________________________________________________ Date of Birth: _________________________________
I authorize my healthcare provider to release my health information to Pulse Medical
Staffing. I understand that this information is disseminated to the facilities as part of my
placement as required by facility and JCAHCO.
Employee Signature: _______________________________________________________ Date: _______________________________________
Physician’s Office No. ______________________________________________________ Physician’s Fax No._____________________________
Applicant – DO NOT WRITE BELOW THIS LINE
--------------------------------------------------------------------------------------------------------------------------------------------------------------
The above patient has been seen by me and has been found to be in good mental and
physical health, free of communicable disease, and able to function in the healthcare
profession without any physical limitations.
Today’s Date: ________________________________________
Date of last visit: ______________________________________
Physician’s Printed Name: ___________________________________________________ Physician’s Signature: ______________________________________________
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Immunization’s Statement
Employee Name: _________________________________________________________ Date of Birth: _________________________________
OSHA requires that all healthcare workers at risk of acquiring the HBV be vaccinated. By signing below
I certify that I have the general education regarding exposure to the blood borne pathogens as
required by OSHA. I further understand that I should follow each facilities training and policy
regarding blood and body fluids.
I hereby verify that these statements are truthful and accurate.
Employee Signature: _______________________________________________________Date: ________________________________________
Hepatitis B
□ I decline the vaccine due to I have received the series.
□ I have completed the vaccine series on the following date: ___________________________
Tuberculosis
Last TB skin test (PPD) Date’s: 1) _______________________ 2) _____________________________
If positive TB skin test (PPD) Date: _________________________________Last chest X-ray Date: __________________________
MMR Vaccination Date’s: 1) ___________________________ 2) _____________________________
If positive/exposed Date: _______________________________
Varicella
Vaccination Date’s: 1) ___________________________ 2) _____________________________
If positive/exposed Date: _______________________________
620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677
Policy on Confidentiality and Dissemination of Patient Information and Staff Member Verification Given the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course or our work. Pulse Medical Staffing prohibits the release of any patient information to anyone outside the department or facility except in limited circumstances and discussions or disclosures of protected health information (PHI) within the organization should be limited to the minimum necessary that is needed for the recipient of the information to perform their job. Acceptable uses of PHI within the organization include but are not limited to peer review, internal audits, quality assurance and billing. I understand Pulse Medical Staffing provides services to area healthcare facilities patients that are private and confidential and that I am a crucial step in respecting the privacy rights of these patients. I understand that it is necessary, in the rendering of Pulse Medical Staffing services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected by federal and state laws that prohibit its unauthorized use or disclosure. I have received training in the confidentiality policies and procedures set in place by Pulse Medical Staffing, listed in my personnel file and agree I will comply with such policies and procedures during my entire employment with Pulse Medical Staffing. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify Pulse Medical Staffing HIPAA Privacy Officer Liaison immediately. In addition, I understand that breach of patient confidentiality or privacy may result in disciplinary action up to and including suspension or termination of my employment with Pulse Medical Staffing. Upon separation of my employment for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. I have read and understand all privacy policies and procedures that have been provided to me by Pulse Medical Staffing. I agree to all conditions of my employment set forth in this agreement. This is not a contract of employment and does not alter the nature of the at-will employment relationship between Pulse Medical Staffing and me. Signature: ________________________________________ Date: ______________________ Printed Name: _____________________________________ Reviewed by: ______________________________________