Dates Worked

Dates Worked

PLEASE READ AND SIGN

I hereby authorize Clinical Staffing Resources, and also authorize and reqeust each former employer and person, firm or corporation given as a reference to answer all questions that may be asked and give all information that may be ought in connection with this application specifically concernning my work, skill or my professional action in any transaction. My employment with Clinical Staffing Resources wil not begin until such refrences are received.

I agree, in consideration of your employing me that I will not seek or accept employment from any client of Clinical Staffing Resources without first obtaining permission from Clinical Staffing Resources. I also understand that I am not to accept employment from any Clinical Staffing Resources client for which I have been presented or worked for a period of 180 days from the last day of scheduled work or date presented to the client as a candidate. I understand that if I am in violation of this agreement, I am subject to legal action and monetary damages.

I understand taht this employment application is not a contract and that if hired, my employment with Clinical Staffing Resources can be terminated with or without cause, and with or without notice, at my time, at the option of Clinical Staffing Resources. I also understand that any and all benefits received pursuant to employment with Clinical Staffing Resources may be changed or eliminated at will without prior notice.

I consent to having a background check done on my history, including a social security number verification, and I understand that my employment might hinge on this check, inclding termination if after I am hired, Clinical Staffing Resources acquires information that precluded my hire.

I understand that all applicants are required to undergo screening for the presence of illegal drugs or alcohol as a condition of employment at Clinical Staffing Resources I will be required to voluntarily submit to a urinalysis test at a laboratory chosen by the company and by signing this consent agreement I release Clinical Staffing Resources from liability. I understand that with positive test result. I will be declined employment at this time, but I may initiate another inquiry with Clinical Staffing Resources, after 6 months. Clinical Staffing Resources, will not discriminate against applicant for employment because of past abuse of alcohol/drugs. Neither will Clinical Staffing Resources tolerate the current abuse of alcohol/ drugs. I may also be asked to voluntarily submit to urinalysis tests for Cause/ Post incident Screening, Post Accident Screening and at the request of any client prior to starting an assignment.

I authorize Clinical Staffing Resources to copy and forward my personnel file contents to any and all agencies which require this Clinical Staffing Resources. I hereby certify that all of hte above information is true and correct. I understand that any misrepresentation or false information given on this application will result in rejection or termination of employment.

PRIMARY CONTACT

SECONDARY CONTACT

Annual Mandated Topics

I hereby acknowledge receipt and understanding of the following Mandated Topics from Clinical Staffing Resources:

Topics Included:

>   Fire Safety
>   Electrical Safety
>   Infection Control / Universal Precautions
>   Hepatitis C
>   Hepatitis B
>   HIV Testing and Related Information
>   Age Specific Care
>   Sexual Harassment
>   Pain Management
>   Patient Abuse
>   Multi-Cultural Aspects and Spiritual Diversity of Patient Care
>   HIPAA Privacy Regulations
>   National Patient Safety Goals
>   Patient Rights
>   Domestic Violence
>   Restraints
>   Blood Glucose Monitoring & Management
>   Advance Directives
>   Agency Administrative Policies and Procedures
>   Emergency Preparedness Plan
>   Prevention of Medical Errors
>   Back Safety
>   Workplace Violence

I understand that as an employee of Clinical Staffing Resources, at any client facility, it is my responsibility to protect the confidentiality of the patients' medical information. Failure to maintain patient confidentiality may lead to discharge or other disciplinary action.

I have read and understand the above policy.

Hepatitis B Status Declaration
*Please select Decline or Accept

Reference Request *

The following employment information must be provided to Clinical Staffing Resources, in accordance with there stringent pre-employment requirements.

I hereby authorize the release of my employment and performance records.

I respectfully request your prompt response to this request for my employment information, as my future employment is dependent on your contribution

Employer Contact Information

Employee Information

Reference Request *

The following employment information must be provided to Clinical Staffing Resources, in accordance with there stringent pre-employment requirements.

I hereby authorize the release of my employment and performance records.

I respectfully request your prompt response to this request for my employment information, as my future employment is dependent on your contribution

Employer Contact Information

Employee Information

Please check the appropriate boxes to describe your experience level with each skill listed below.

Key to Competency Levels:
0 - No Experience
1 - Minimal experience, ned review and supervision, have performed at least once
2 - Comfortable performing with resource available
3 - Competent to perform independently and safety
4 - Expert, able to act as resource to others

Scale Use:

Use of Electronic VS Equipment:

Administering Enemas:

Aspiration Precautions:

Collecting Urine:

Bathing / Daily Hygiene:

Proper Use of Specific Barrier Methods:

Application of Restraints

New Admissions and Transfer:

Patient Care:

Maintaining 02 Therapy:

Preparation for and transfer to SNF:

Communicating to RN / MD

Recording and Reporting