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.
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Pre-Employment Check List - Pulse Medical Staffing · Skills Checklist ... Assist in intubation/extubation Thoracentesis Chest tube insertion (assist in ... *trach tray set up 2)
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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)
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
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):
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):
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: ______________________________________