q Shift Application

Personal Information
     
First Name: MI: Last Name: Discipline (RN, LPN, PT, Rad Tech, etc.)
* * *
Social Security      
     
Present Address:      
Address: City: State: Postal Code:
Phone: Best Time To Reach You: Fax Number: Date Available To Travel?
*
Permanent Address:      
Address: City: State: Postal Code:
* * * *
Phone: Do You Have E-mail Access? *E-mail Address:  
*  
Referred to q Shift By:      
     
 

Alternate Contact:
*Contact Name:  *Phone:
*Relationship:
*Address:
*City:  *State: *Postal Code:
q Shift is authorized to make emergency contact as indicated and to discuss personal/protected health information regarding the emergency with my designated alternate contact at any time q Shift deems a situation to be an emergency, with or without my verbal consent.
 

Education:
  *Name and Location of School *Date Graduated: *Degree/Certificate:
*Basic Professional Education:
Additional Professional Education:
 

Nursing / Professional Licensure:
State License/Cert# Exp. Date State License/Cert# Exp. Date
     
Has Your License/Certification (in any jurisdiction that you may have been licensed/certified in)
Ever Been Investigated, Suspended or Revoked? *
If Yes, Please Detail The Dates,
Circumstances, And The Final Outcome
 
Has There Been a Complaint Filed Against Your License/Certification? *
If Yes, Please Explain And List The Dates
 
Do You Have Any Malpractice or Negligence Suits Pending Against You? *
If Yes, Please Give Details Of The Suit And Its Current Status.
 
Have You (in the past seven years) Been convicted of a criminal law violation, Pleaded No Contest to a criminal law violation,
Pleaded Guilty to a criminal law violation, or Been Found Guilty of a criminal law violation?
(Include all such instances even if adjudication was withheld) *
 
 

Certifications:
 *Complete all that apply
Cert Name Exp Date Cert Name Exp Date Cert Name Exp Date
ACLS CHEMO PALS
BCLS/CPR CNOR RNC
BTLS CRRN OTHER
CCRN NALS    
CEN ONC    
Related Courses/Certifications (i.e., EKG, Balloon Pump, etc.)
List Any Additional Education, Skills, Experience, or Other Relevant Qualifications:
 

Clinical Experience:
 *Complete all that apply
Area From: Mth/Yr From: Mth/Yr Area From: Mth/Yr From: Mth/Yr
Burn Neurology
CCU Occupational
CVICU Oncology
Dialysis Operating Room
ER Trauma 1 Prompt Care
ER Level 2 Pediatrics
ER Triage PICU
GYN Psychiatry
L&D PACU
L&D High Risk Rehabilitation
Medical-Surgical SICU
MICU Step Down/PCU
Mother-Baby Telemetry
NICU 3      
NICU 2      
 

Previous Employment:

Please complete all information for each previous employer. Please provide the name of the agency as well as the name
of the facility. Note: Three years of previous employment information is required. Start with most recent employment first.
*Facility #1
*Name   *Reason for leaving
*Address   *Immed. Supervisor
*City, State, Zip   *Unit Worked, Specialty
*Phone(s)   Number of Beds Unit:   Hospital:
*Dates Employed From (Mth/Yr): To (Mth/Yr):   *May We Contact Your Current Employer?
 *Teaching? Teaching/Non-Teaching   *Charge Experience?
  Was This a Travel Assignment?   If Yes, With Which Agency?
Facility #2
Name   Reason for leaving
Address   Immed. Supervisor
City, State, Zip   Unit Worked, Specialty
Phone(s)   Number of Beds Unit:   Hospital:
Dates Employed From (Mth/Yr): To (Mth/Yr):   May We Contact This Employer?
 Teaching? Teaching/Non-Teaching   Charge Experience?
  Was This a Travel Assignment?   If Yes, With Which Agency?
Facility #3
Name   Reason for leaving
Address   Immed. Supervisor
City, State, Zip   Unit Worked, Specialty
Phone(s)   Number of Beds Unit:   Hospital:
Dates Employed From (Mth/Yr): To (Mth/Yr):   May We Contact This Employer?
 Teaching? Teaching/Non-Teaching   Charge Experience?
  Was This a Travel Assignment?   If Yes, With Which Agency?
Facility #4
Name   Reason for leaving
Address   Immed. Supervisor
City, State, Zip   Unit Worked, Specialty
Phone(s)   Number of Beds Unit:   Hospital:
Dates Employed From (Mth/Yr): To (Mth/Yr):   May We Contact This Employer?
 Teaching? Teaching/Non-Teaching   Charge Experience?
  Was This a Travel Assignment?   If Yes, With Which Agency?
Facility #5
Name   Reason for leaving
Address   Immed. Supervisor
City, State, Zip   Unit Worked, Specialty
Phone(s)   Number of Beds Unit:   Hospital:
Dates Employed From (Mth/Yr): To (Mth/Yr):   May We Contact This Employer?
 Teaching? Teaching/Non-Teaching   Charge Experience?
  Was This a Travel Assignment?   If Yes, With Which Agency?
 
Please explain all gaps of two months or more in employment history
Have you ever been fired, asked to resign, suspended, or received written discipline?
   If yes, please explain.
 

Professional References:

Appropriate references are department heads, supervisors, and/or nurse managers
 with whom you have worked in the past two years. Give the full name and title.
*2 References Required
*Reference #1        
*Name   *Title
Home Address   City, State, Zip
Home Phone   *Work Phone
*Hospital in which you worked with this reference   *Facility City, and State
*Was this a travel assignment? If yes, with which
company?		 *Dates
         
*Reference #2        
*Name   *Title
Home Address   City, State, Zip
Home Phone   *Work Phone
*Hospital in which you worked with this reference   *Facility City, and State
*Was this a travel assignment? If yes, with which
company?		 *Dates
         
Reference #3        
Name   Title
Home Address   City, State, Zip
Home Phone   Work Phone
Hospital in which you worked with this reference   Facility City, and State
Was this a travel assignment? If yes, with which
company?		 Dates
         
Reference #4        
Name   Title
Home Address   City, State, Zip
Home Phone   Work Phone
Hospital in which you worked with this reference   Facility City, and State
Was this a travel assignment? If yes, with which
company?		 Dates
 

Placement Profile:
Desired Contract Length: *What Date Can you Start:    
Areas of Clinical Experience:
Length of Experience in Above Areas
Geographical Preference:
Shift Preference:
Clinical Area Preference:
States You Currently Hold A Professional License/Certification
States You Have An Expired Professional License/Certification
What Are The Most Important Factors You Will Be Looking For When Choosing a Travel Assignment?
What Complaints/Criticisms Do You Have About Past Travel Agencies or Past Travel Assignments?
Housing Request:  Private/Subsidy (You Will Not Need Agency Provided Housing.)
Will A Partner Be Traveling With You?  If Yes, Name:
Will Children Be Traveling With You?  If Yes, Names, Ages:
Will A Pet Be Traveling With You?  If Yes, Type, Breed, Weight:
 
I certify that the answers given by me to the foregoing questions and statements are all true and correct to the best of my knowledge.  I agree that q Shift Nurses shall not be liable in any respect if my employment is terminated because of false statements or answers or misleading omissions made by me in this application. I also authorize the companies, schools, or persons named above to give any information they may have regarding me, whether or not it is in their records. I hereby release said companies, schools, or persons from all liability for any damages for issuing this information.  I understand that this employment application and any company handbook’s I may receive do not constitute contracts of employment or benefits.  I authorize q Shift Nurses to release this application along with other information to prospective client facilities for an employment decision through q Shift Nurses.  I hereby release q Shift Nurses, its employees, and any individuals or entity providing information to q Shift Nurses from all liability from any damages from the disclosure of this information.
 
 I agree with the terms, stated above, of the q Shift Employment Application.  Date: