* Required Information
Personal Information

WORK HISTORY

Education

I Hereby authorize clinical staffing Resources, and also authorize and request each former employer and person or corporation given as a reference to answer all questions that may be asked and give all information that may be sought in connection with this application specifically concerning my work, skill or my professional action in any transaction. My employment with Clinical Staffing Resources will not begin until such references are Deceived.

I agree in consideration of your employing me that I will not seek or accept employment form any client of Clinical Staffing without first obtaining permission from Clinical Staffing Resources client for which I have been presented or worked for a period of 180 days from the Last days 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 that 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 any time, at the option of Clinical Staffing Resources. I also understand that any and all benefits received pursuant to eraployment with Clinical Staffing Resources may be changed or eliminated will without prior notice.

I consent 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, including 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 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 results I will be agreed employment at this time, but I may initiate another inquiry with Clinical Staffing Resources, after 6 months. Clinical Staffing Resources, will not discriminate against applicants 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 authorized Clinical Staffing Resources to copy and forward my personnel file contents to any all agencies which require this of Clinical Staffing Resources. I hereby certify that all of the above information is true and correct. I understand that any misrepresentation of false information given on this application will result rejection or termination of employment.

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Mandatory Emergency Contact Form

Acknowledgement Form

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.

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Hepatitis B Status Declaration
*Please select Decline or Accept

Do not sign both the Acceptance and Declination protion of this form. If you have any uncertainty regarding your current status. Please contact your Clinical Staffing Resources representative for clarification. If you are unable to provide the required Vaccination Information at this time, Please sign the Declination Portion of this document.

Hepatitis B Declination

I understand that my occupation may result in exposure to blood or other potentially infectious materials, and that I may be at risk of acquiring Hepatitis B virus (HBV) infection. I undestand that my failure to receive this vaccine may subject me to the risk of acquiring Hepatitis B disease or, I am in the process of receiving inoculations for Hepatitis, but I have not completed them yet. Therefore, for now I decline and I will furnish you proof of my inoculations when they are completed.

Hepatitis B Acceptance

I have already received 3 vaccination required for Hepatitis B Vaccination Series and I am able to provide the vaccination records as proof of these inoculations at this time.

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

Skills Checklist

Check the area(s) in which you have experience and indicate the length of time (# of months or years) for each area checked:

Areas of Practice * Months or Years (Put "0" if not applicable)
Med/Surg
ER
Pediatrics
Chemotherapy
OR
Telemetry
Home Care
Rehab Nursing
Oncology
ICU/CCU
Neonatal ICU
Chemo Certified
Aide Supervisor
Educator
CHHA/LHCSA
Other
OB GYN
Pediatric ICU
Nursery
Aide Training
Infusion Therapy
Supervisor/Manager
LTCF
Other

Check the competency/skill(s) in which you have experience and indicate the length of time (# months or years) for each competency/skill checked:

Areas of Practice * Months or Years (PUT "0" IF NOT APPLICABLE)
History/Physical/Mental Assessment
Newborn/Pediatric Assessment
Postpartum Assessment
Client/Family/Caregiver Teaching
Care Provider Supervision
Care/Provider Teaching
Infection Control/Bag Techniques
Documentation
Discharge Process
Transfer Process
Obtaining Physician Orders
Foley Care
Supra-Pubic Catheter Care
Foley Irrigation/Instillation
Ostomy Care - Type:
Medication Administration-Oral
Injection Techniques
IV Administration
Infusion Pump - Type:
NG - Tube Care/Changes
G-Tube/Peg-Tube-Care
Tube Feeding/Irrigation
Wound Care
Decubitus Care
Glucose Monitoring Procedures
Tracheotomy Care
Ventilator Management
Rehab/ROM
Equipment Use - Type:
Equipment Maintenance

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