1120 Randolph St, Suite 42Thomasville, NC 27360

888-272-7427 Toll Free Phone866-743-6335 Toll Free Fax

Email: Recruiting@providencestaffing.comWeb: www.providencestaffing.com

EMPLOYMENT CHECKLIST

Here is a list of items that are needed to begin the interviewing process:

Employment Application Employment History or Current Resume’ Skills Checklist Copy of Driver’s License Copy of Social Security Card Copy of Current Nursing License(s) Copy of CPR Card and other Certifications Copy of Authorization Release Form Reference forms or Reference Letters (2)

When making copies, please make sure all copies are clear and legible with license numbers and expiration dates visible. Please copy both sides of all licenses and certifications. These are OSHA, DHEC and JCAHO mandates. Please return requested information via mail/fax/email. Thank you for choosing Providence Health Care Staffing.

Sincerely,Providence Health CareRecruiting Department

EMPLOYMENT APPLICATION(Please print or Type)

DATE:______________________________

Name:_______________________________________________________________________________Last First Middle Initial

Temporary Address:____________________________________________________________________Number Street City State Zip

Phone: ( ) _______________________ ______________________ Area Code Number Will Be At This Location Until Best times/Day to Reach You

Permanent Address:____________________________________________________________________Number Street City State Zip

Phone: ( ) _______________________ Birth Date:_____________ Area Code Number Best times/Day to Reach You

Referral Source/Name:_____________________ Email Address:___________________________ Friend, Magazine, Journal, Newspaper

U.S. Social Security Number:________________ Canadian Social Security Number:____________

Can you, upon employment, submit verification of your legal right to work in the United States? Yes No

EMPLOYMENT INFORMATION

RN LPN Tech Other Specialty:_____________________ Date You Can Begin:_______________

I am interested in a: Travel Assignment Permanent Position

Areas of Clinical Experience 1._________________ 2._________________ 3.__________________

Length of Experience in Above Areas: 1._________________ 2._________________ 3.__________________

Geographical Preference: 1._________________ 2._________________ 3.__________________

LICENSURE(Include copies of all state licenses) Original State:_______ License #:________________ Exp. Date:__________

State:____ License #:_______________ Exp. Date:______ State:______ License #:________________ Exp. Date:__________

State:____ License #:_______________ Exp. Date:______ State:______ License #:________________ Exp. Date:__________

Have you ever had disciplinary action taken against any of your state licenses? Yes No

Have you ever been named as a defendant in a malpractice claim? Yes No

Have you ever been convicted of a felony (other than a minor traffic violation) Yes No

If yes, on any of the above, please attach separate sheet with explanation.

EDUCATION Name and Location of School GraduatedY/N

Diplomas, Degrees Received

Nursing School

College

Graduate School

What month and year did you pass U.S. nursing boards/registration exams?___________ Canadian Nursing Boards?____________

Date CPR Certified:___________________________________________ CPR Expiration Date:_____________

Additional Certifications (i.e., ACLS, CCRN, etc.)____________________________________________________________________

EMPLOYMENT HISTORY (Please print or Type)

Name:_______________________________________________________________________________ Last First Middle Initial

Are you currently employed? Yes No If so, may we inquire of your present employer? Yes No

Please list your employment history below. If working through an agency, please indicate the specific facility in which you are working, the supervisor at the facility, as well as the name of the agency. You may include verifiable volunteer work. Please document reasons for periods of unemployment. Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:___________________________ Average Patient Caseload:_________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

Facility:__________________________________________ Non-Teaching Teaching No. of Facility Beds:_________

Address:_________________________________________ City:____________________ State:______ Zip:_________

Dates Employed: From:________________ To: ________________ Reason for Leaving:______________________________

Specialty Unit(s) Worked In:___________________________ No. of Unit Beds:_________ Charge Experience? Yes No

Position Held:__________________________ Average Patient Caseload:__________ Shift Worked:______ Hrly Rate:_________

Facility Supervisor’s Name and Title:__________________________________ Phone: ( ) Ext:_______

Agency (if Applicable):_____________________________________________ Phone: ( ) Ext:_______

MEDICAL/SURGICAL SKILLS CHECKLIST KEY:

Place an X in the column best describing your expertise level according to the following scale:

1 - No Experience

2 - Limited Experience; Performs Intermittently

3 - Moderate Experience; Needs Resource for Backup

4 - Experienced; Performs Independently

1 2 3 4 1 2 3 4NEUROLOGICAL SYSTEM CARDIOVASCULAR SYSTEM - continued

Assess Cranial Nerves Care of Patients With:

Assess Level of Consciousness Acute CHF

Assess Sensory Motor Functions – Extremities Aneurysm

Assist with Lumbar Puncture Blood Lymph Disease

Care of Patients with: CVA

Acute Head Injury Cardiac Surgeries

Aphasia Femoral Bypass / Vascular Procedures

Autonomic Dysreflexia Pacemakers

CVA Transplant - Cardiac

Cancer of the Brain RESPIRATORY SYSTEM

Craniotomy Ambu Techniques

Head Trauma Apnea Monitor Usage

Impending D.T.s Assess Lung Sounds

Multiple Sclerosis Knowledge of Abnormal and Adventitious

Breath sounds Parkinson’s Care of Patients With:

Quadriplegia AIDS / Wheezing

Seizure Disorders CA of the Lung

Spinal Cord Injury COPD

Documentation of Seizures Emphysema

Halo Traction Pneumonia

Pre/Post Op Neuro Surgical Care TB

Seizure Precautions Transplant – Pulmonary

Shunts (i.e.: ventriculopertioneal) Chest Tube Maintenance and Care

Use of Anticonvulsants: IPPB Machine

IM Incentive Spirometer

IV Nebulizers

PO Oxygen Therapy:

Use of Glascow Scale Face Mask

CARDIOVASCULAR SYSTEM Nasal Cannula

Ability to perform 1 Person Rescue Precautions

CPR Adult Use of Portable Oxygen Tank

CPR Infant / Child Pulmonary Hygiene

Assess Heart Sounds (normal vs abnormal) Chest Physiotherapy (CPT)

Basic EKG Interpretation Determining Proper Catheter Size

Set-up / Run 12 Lead EKG Nasotracheal Suctioning

Use of Cardiac Monitor Oral Suctioning

Use of Doppler Tracheostomy Suctioning

Initiation of Arrest Procedure Thoracentesis

Administration of Meds During a Code Tracheostomy:

Changing Trach or Tube

Page 1 of 4

MEDICAL / SURGICAL SKILLS CHECKLIST – (continued)1 2 3 4 1 2 3 4

RESPIRATORY SYSTEM - continued GI / NUTRITION - continued

Tracheostomy (continued): Parenteral Feedings

Cleaning or Inner Cannula Complications Of

Emergency Management of Indications For

Dressing Changes Routes of Administration

S&S Of Infection Verification of Fluid & Caloric Requirements

Skin Care Use of Pumps for Parenteral Feedings

Ventilators List Types of Pumps

CPAP Brand:

PEEP Brand:

Portables Brand:

Pressure Pre-Set GU / REPRODUCTIVE / ENDOCRINE

Volume Pre-Set Bladder Irrigations

List Types of Ventilators: Bladder Training

Brand: Care, Maintenance & Removal of:

Brand: Indwelling Foley Catheter

Brand: Supra Pubic Catheter

Brand: 3-Say Catheter

GI / NUTRITION Care of Patients With:

Abdominal Drains Care and Maintenance AV Shunt / Fistula

Assess GI Status Bladder Disease

Bowel Training Cancer of Kidney

Care of Patients With: Cancer of Prostate

Anorexia Female Reproductive Organ Cancer

Bowel Disease Hysterectomy

Cancer of Colon Hypo/Hyperthyroidism

Cancer of Esophagus Mastectomy

Cancer of Rectum Nephrectomy

GI Bleeds Renal Failure

Hepatic Encephalopathy Transurethral Resection

Hepatitis Catheter Insertaion

Inflammatory Bowel Disease Male

Liver Failure Female

Liver Transplant Diabetic Care

Enemas (Fleets or Soapsuds) ADA Diet

Gastrostomy Tube Care: Blood Glucose Testing

G-Tube Change Foot Care

G-Tube Feedings Infection Prevention

Nasogastric Tube Care: Insulin Prep and Administration

Insertion / Reinsertation Education

N-G Tube Feedings Skin Care

Salem Sump S&S Hypo / Hyperglycemia

Nasla Intentinal Tubes (i.e. Miller-Abbot,

Cantor)

Urine Glucose Testing

Ostomy / Stoma Care Use of Blood Test Meters

Ostomy Irrigations Dialysis

Ostomy Patient Education Hemo

Paracentesis Peritoneal

Removal of Fecal Impactions Ileostomy Care

Urinary Diversions

Page 2 of 4

MEDICAL / SURGICAL SKILLS CHECKLIST – (continued)1 2 3 4 1 2 3 4

INTEGUMENTARY / ORTHOPEDIC INFUSION THERAPY - continued

Amputations / Stump Care Blood / Blood Products Administration

Assist In Use of Prosthetic Devices Calculate Dosages

Care of Patients With: Calculate Rates

Amputation Care of Central Lines:

Arthritic Disease Care of Insertion Site

Burns Dressing Changes

Pressure Ulcers Hanging IV Piggybacks

Gun Shot Infusion Procedures

Hip Replacement Pump Operations:

Incisions IMED

Knee Replacement IVAC

Laminectomy Other (specify):

Skin Cancer Record Keeping

Stab Wounds S&S of Complications

Cast Care S&S of Infection

Cast / Splint Application and Removal S&S of Infiltration

Circo-Electric Bed Insertion of Peripheral Line

Range of Motion Adult

Spika Cast Child

Stryker Frame Elderly

TENS Intralipids

Traction: Nursing Care, Maintenance of:

Skeletal Broviac Catheter

Skin Buretois

Transfers Heparin / Saline Lock

Wound Care: Insertion of Heparin / Saline Lock

Documentation of Wounds Hickman Catheter

Preventative Skin Care Peripheral Lines

Sterile Dressing Changes Porta-Cath

Use of Braden Scale Triple Lumen Catheter

Wound Enzyme Debriders OTHER NURSING RESPONSIBILITIES

Wound Irrigations Admission Procedure / Initial Assessment

ONCOLOGY Charge Nurse Responsibilities

Assessing Analgesic Effectiveness Discharge Planning & Teaching

Bone Marrow Transplant Injections

Counseling for: Preparation of Meds / Syringe

Altered Image Record Keeping

Grieving Process Site Prep / Rotation / Selection

Imagery Knowledge of Unit Dose

Relaxation Techniques Lab Value Interpretation

Morphine Pumps Pre / Post-Op Teaching

Narcotics via Continuous Infusion Primary Nurse Responsibilities

Radiation Therapy Problem Oriented Medical Records

Radioactive Implants SOAP Charting

Side Effects of Chemotherapy Team Leading

INFUSION THERAPY Universal Precautions / Procedures

Administration of Chemotherapy Use of Restraints

Administration of IV Meds

Page 3 of 4

MEDICAL / SURGICAL SKILLS CHECKLIST – (continued)OTHER NURSING RESPONSIBILITIES-continued CERTIFICATIONS Exp. DateSpecimen Collection ACLS

Arterial Blood Gas Draw BCLS

Arterial Blood Gas Values Interpretation Chemotherapy

Capillary Draw Diabetic Certification

Clean Catch Urine IV Therapy

Heelstick Med-Surg

Sputum Other

Stool Other

24 hr Urine via Indwelling Catheter Other

Venipuncture Wound Culture

SPECIALTY COURSE (NAME) DATE LOCATION1.

2.

3.

Detail any additional experience which makes you exceptionally qualified to practice as a traveling nurse.

What additional languages do you speak?

____________________________________________________________________________________

_____________________________________________________ ____________________________Traveler's Signature Date

Page 4 of 4

AUTHORIZATION RELEASE

I, ____________________________ authorize my employers, law enforcement agencies, school and/or persons who may assist Providence Health Care Staffing in determining my suitability for employment, to provide reference information to Providence Health Care Staffing. I hereby release all such employees, individuals, and/ or organizations contacted from all liabilities for issuing this information to Providence Health Care Staffing. I also authorize Providence Health Care Staffing to disclose this information to a client facility only after receiving my consent on each job opportunity.

____________________________ _____________________________ Applicant’s Signature Social Security Number

Dear Employer,

The individual named above has applied with Providence Health Care Staffing for employment in the healthcare field and has submitted your name for reference purposes. We would appreciate your reply and assure you that your answers will be held in strict confidence.

______________________________________ Providence Health Care Staffing Representative

1120 Randolph St, Suite 42Thomasville, NC 27360Phone: 888-272-7427Fax: 866-743-6335

REFERENCE FORM(Please print or Type)

TO BE COMPLETED BY TRAVELER

Applicant’s Name:_____________________________________________________________________

Classification: RN LPN CRTT RERT RTT Rad Tech ST CST

Clinical Specialty:_________________________________________________ Travel Assignment: Yes No

Employment dates: From:___________________________ To:__________________________________

Facility Name:_________________________________________________________________________________

City:_____________________________________________________________ State:_____________________

Contact:_____________________________________________________ Phone #: ( )_________________

TO BE COMPLETED BY FACILITY OR AGENCY

Please indicate whether the above information is correct: Yes No

Average patient caseload: ________________ # of beds on unit: _________ Charge Experience: Yes No

Teaching Non-Teaching # of beds in facility: _____________________________________

Reason for leaving: _______________________________________________ Would you rehire? Yes No

Please select a rating for each of the following:

Above BelowExceptional Standard Standard Standard

Performance Evaluation:1. Demonstrates competency in caring for patients……….. 2. Provides a safe and therapeutic patient environment… 3. Implements a coordinated plan of patient care………….. 4. Adheres to facility policies and procedures………………….. 5. Communicates appropriately with patients & families…. 6. Completes accurate documentation of patient care……..

Professional Attributes:7. Flexibility and adaptability…………………………………………….. 8. Willingness and ability to float (if applicable)………………. 9. Interest and enthusiasm……………………………………………….. 10. Ability to communicate with staff………………………………….. 11. Attendance and punctuality…………………………………………… 12. Overall professionalism………………………………………………….

Comments:____________________________________________________________________________________

_____________________________________________________________________________________________

_______________________________________________ ____________________ ____________________ Evaluator/Title Date Phone

This information was obtained from: Written reference Verbal Reference

Evaluation Recommendation Letter

REFERENCE FORM(Please print or Type)

TO BE COMPLETED BY TRAVELER

Applicant’s Name:_____________________________________________________________________

Classification: RN LPN CRTT RERT RTT Rad Tech ST CST

Clinical Specialty:_________________________________________________ Travel Assignment: Yes No

Employment dates: From:___________________________ To:__________________________________

Facility Name:_________________________________________________________________________________

City:_____________________________________________________________ State:_____________________

Contact:_____________________________________________________ Phone #: ( )_________________

TO BE COMPLETED BY FACILITY OR AGENCY

Please indicate whether the above information is correct: Yes No

Average patient caseload: ________________ # of beds on unit: _________ Charge Experience: Yes No

Teaching Non-Teaching # of beds in facility: _____________________________________

Reason for leaving: _______________________________________________ Would you rehire? Yes No

Please select a rating for each of the following:

Above BelowExceptional Standard Standard Standard

Performance Evaluation:1. Demonstrates competency in caring for patients……….. 2. Provides a safe and therapeutic patient environment… 3. Implements a coordinated plan of patient care………….. 4. Adheres to facility policies and procedures………………….. 5. Communicates appropriately with patients & families…. 6. Completes accurate documentation of patient care……..

Professional Attributes:7. Flexibility and adaptability…………………………………………….. 8. Willingness and ability to float (if applicable)………………. 9. Interest and enthusiasm……………………………………………….. 10. Ability to communicate with staff………………………………….. 11. Attendance and punctuality…………………………………………… 12. Overall professionalism………………………………………………….

Comments:____________________________________________________________________________________

_____________________________________________________________________________________________

_______________________________________________ ____________________ ____________________ Evaluator/Title Date Phone

This information was obtained from: Written reference Verbal Reference

Evaluation Recommendation Letter

REFERENCE FORM(Please print or Type)

TO BE COMPLETED BY TRAVELER

Applicant’s Name:_____________________________________________________________________

Classification: RN LPN CRTT RERT RTT Rad Tech ST CST

Clinical Specialty:_________________________________________________ Travel Assignment: Yes No

Employment dates: From:___________________________ To:__________________________________

Facility Name:_________________________________________________________________________________

City:_____________________________________________________________ State:_____________________

Contact:_____________________________________________________ Phone #: ( )_________________

TO BE COMPLETED BY FACILITY OR AGENCY

Please indicate whether the above information is correct: Yes No

Average patient caseload: ________________ # of beds on unit: _________ Charge Experience: Yes No

Teaching Non-Teaching # of beds in facility: _____________________________________

Reason for leaving: _______________________________________________ Would you rehire? Yes No

Please select a rating for each of the following:

Above BelowExceptional Standard Standard Standard

Performance Evaluation:1. Demonstrates competency in caring for patients……….. 2. Provides a safe and therapeutic patient environment… 3. Implements a coordinated plan of patient care………….. 4. Adheres to facility policies and procedures………………….. 5. Communicates appropriately with patients & families…. 6. Completes accurate documentation of patient care……..

Professional Attributes:7. Flexibility and adaptability…………………………………………….. 8. Willingness and ability to float (if applicable)………………. 9. Interest and enthusiasm……………………………………………….. 10. Ability to communicate with staff………………………………….. 11. Attendance and punctuality…………………………………………… 12. Overall professionalism………………………………………………….

Comments:____________________________________________________________________________________

_____________________________________________________________________________________________

_______________________________________________ ____________________ ____________________ Evaluator/Title Date Phone

This information was obtained from: Written reference Verbal Reference

Evaluation Recommendation Letter