Name, Address, Contact Information

Pursuant to Title VII of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq.) and 45 C.F.R. Part 80, Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794) and 45 C.F.R. Part 84, and the Age Discrimination Act of 1975 (42 U.S.C. § 6101 et seq.) and 45 C.F.R Part 91, the agency adheres to an equal opportunity policy for all persons seeking admission a clients, or seeking employment, and for all persons employed by the agency. The agency does not discriminate because of age, race, color, religion, military status, martial status, gender preference, sex, national origin, or disability.

TSNC-online-application-RN-LPN-JD-020713.doc Last printed 6/6/2007 8:44:00 AM Page 1 of 11

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Employment Application Date: , 20___

Name, Address, Contact Information

Last Name First Name Middle Name

- - - - - - - - Soc. Sec. No. Home Phone No. Cell Phone No. Other Phone Ext.

@ .

@ .

Email 1 Email 2

- Street Address Apt City State Zip

Job Information

Position (Job Class) Applying For

RN LPN CNA PCA SITTER

OTHER (Describe):

Work Experience/Skills

(List the number of years experience [minimum 1-year] and are clinically or practically competent, respectively)

Previous Home Care: -years Range of Motion: -years Cushion pressure check: -years

Bowel Program: -years SCI: -years Cushion pressure adjust: -years

Drive Van: -years S/P Cath Change: -years Chair Lift/Van: -years

G-Tube Feeds: -years TBI: -years Scooter Lift: car trunk: -years

Geriatric: -years Trach Suction: -years Household tasks: -years

Glucometer: -years Ventilator: -years Meal Prep (cooking): -years

Hospice: -years Wound Care: -years -years

Hoyer Lift: -years Scooter Charging: -years -years

InExsufflator: -years Manual Chair: -years -years

Intermittent Cath: -years Powerchair Charging: -years -years



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Other Specialty:

Type of Employment Desired: Type of Shifts Desired:

Per Diem 8 Hour Shifts

Contract 10 Hour Shifts

Direct 12 Hour Shifts

Shift Preference Day Evening Weekend

License(s)/Certification(s)

License Type: ACLS Exp. Date: - -

License Number: BCLS Exp. Date: - -

State: PALS Exp. Date: - -

Expiration Date: - - NALS Exp. Date: - -

NRP Exp. Date: - -

License Type: Other: ; Exp Date: - -

License Number:

State: Drivers License State:

Expiration Date: - - Drivers License Number:

Drivers License Exp.: - -

License Type:

License Number:

State:

Expiration Date: - -



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Employment Qualification 1. Are you legally authorized to work in the United States? Yes No

2. If no, are you legally employable in the U.S.? Yes No

3. Have you ever been bonded? Yes No

4. Have you ever applied with Essential Staffing or The Specialty Nurse Company?

Yes No

5. Have you been convicted of any misdemeanor or felony within the last 7 years?

Yes No

a. If Yes, Please Explain:

Yes No

6. HAVE YOU HAD ANY PROFESSIONAL LICENSE SUSPENDED, REVOKED OR UNDER INVESTIGATION?

Yes No

a. IF YES, PLEASE EXPLAIN:

7. Do you have any allergies? PLEASE LIST ANY ALLERGIES YOU MAY HAVE:

; ; ; ; ;

Yes No

Work History/Experience List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment.

Attach additional sheet(s) if necessary.

1.

From: - - To: - - Dates Employed

Facility Name/Employer

-

Street Address City State Zip

Your Title Unit Number of Beds



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- - ext. - Supervisor’s Name Telephone Number State Zip

HRLY$ . YRLY$ .00 No, Employee Yes, Travel Assignment Pay Rate/Salary Was this a travel assignment?

Yes: PQ/ESPS may contact this Supervisor/HR. No

May We Contact via Supervisor/HR?

2.



-







3.



-




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Yes: PQ/ESPS may contact this Supervisor/HR Dept. No

May We Contact via Supervisor/HR Dept?

4.



-







Educational Information

What is the highest clinical degree/certification received?

School Name City State

Degree Type:

Year Graduated from School:



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Area of Concentration:

Year Graduated from School:

Do you carry professional liability insurance? Yes No

If yes, any pending claims? Yes No

Explain:

What professional, trade, business or civic associations do you belong to?

Special accomplishments, publications, or awards?

Clinical Experience: (Number of Years)

Locations: 1. 2. 3.

Assignment Preferences (Where do you prefer to go?)

When are you available to start?

First Emergency Contact Information

- - , ext - - Name Work Phone Home Phone

@ . @ . Email 1 Email 2


Second Emergency Contact Information

- - , ext - - Name Work Phone Home Phone

@ . @ . Email 1 Email 2



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The Specialty Nurse Company Inc. Applicant Acknowledgement: I certify that the information in this application is accurate, current and complete. I understand that mis-statements or omissions may result in disqualification from further consideration or termination of employment. I authorize The Specialty Nurse Company, Inc., to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision. I authorize The Specialty Nurse Company, Inc., to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize The Specialty Nurse Company, Inc., to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release The Specialty Nurse Company, Inc., and any individual or entity providing information to The Specialty Nurse Company, Inc., from all liability for any damages from the disclosure of this information. I also understand and agree that: (place initials in boxes below)

Passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be

reasonably accommodated, you may not be hired or employment may be terminated at the company’s sole discretion.

Subject to applicable state laws, the Company reserves the right to conduct drug screening and testing for reasonable suspicion at any time during

employment and as a pre-employment requirement. Any violation of this policy shall result in an applicant not being hired or an adverse employment action up to and including immediate termination. The Specialty Nurse Company, Inc., has the right to change this policy at any time as it requires. I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between The Specialty Nurse Company Inc., and me for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship



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is established, I understand that my employment will be terminable “at will”, that will have the right to terminate my employment at any time, and that The Specialty Nurse Company, Inc., will retain a similar right to terminate my employment at any time. I understand that should I become employed by The Specialty Nurse Company, Inc., my work assignments, schedules and/or work locations are subject to change according to the needs of business and the clients of The Specialty Nurse Company, Inc. I understand that if offered employment, being hired is contingent on me accepting and signing a job description, offer letter with covenants, and other required documents. ________________________________________________

______________ ___, 20_____

Applicant’s Signature Date



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APPLICANT: Signature: Date: / / Print Name:

APPLICANT INFORMATION (Please Print) Account Number: 101-102318 Applicant Name: (First Middle Last) Current Address: (street address)

Other Name(s) Used: (like Maiden) City: State:

Zip:

Gender: * Male Female

Former Address: (1)

Social Security No:* City: State:

Zip:

Driver’s License No.: State: Former Address: (2)

Date of Birth: * Place of Birth: (City, State, Country) City: State:

Zip:

* This information will be used for purposes of background screening only and will not be used in making any employment decisions.

DISCLOSURE AND AUTHORIZATION

NOTICE REGARDING BACKGROUND INVESTIGATION

Employer (“the Company”) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates, including motor vehicle record (or “driving record”) checks, workers compensation records, credit bureau files, employment references, personal references, drug screening, any educational and licensing institution or military branch and to receive any criminal record information pertaining to you which may be in the files of any Federal, State or Local criminal justice agency in Georgia or any other State. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this

A P P L I C A N T ’ S D I S C L O S U R E & A U T H O R I Z A T I O N F O R B A C K G R O U N D

S C R E E N I N G



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notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067, 800-800-3774 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by [the consumer reporting agency] , another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVES-TIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.



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SKILLS AND EXPERIENCE CHECKLIST

RN/LPN – Please write in number of years of experience in each area

To the best of my knowledge, the information given above is true and complete. I understand that any misrepresentation

will be sufficient cause for my dismissal.

(Signature) (Interviewer)

Years Years

Leadership Skills Community Health Ostomy Education

Continuing Education Pediatrics – Ambulatory Years

Diabetes Education Pediatrics – Inpatient Clinician/Education

Ear, Nose, Throat Physician’s Office Head Nurse

Emergency Trauma Post Partum Shift Charge

Enterostomal Thpy. Private Duty Shift Supervisor

Family Nurse Prac. Psychiatry – Outpatient Team Leader

Family Planning Psychiatry – Inpatient

Clinical Skills Geriatric Nurse Prac Public Health

Home Care Radiology Need Recent Training Exp. Home Care Coord Recruiting

ICU – General Rehabilitation Ostomy Care

ICU – Medical School Nursing Hyperalimentation

ICU – Neonatal Substance Abuse I.V. Insertion

ICU – Neurological Supervision I.V. Maintenance

ICU – Pediatric Surgery – Ambulatory NG Tube – Placement

ICU – Respiratory Surgery – Inpatient NG Tube – Irrigation

ICU – Surgical Urology NG Tube Feeding

Infection Control Utilization Review Mechanical Ventilator

I.V. Team

Assessment Skills

Percussion/Postural Drainage

Labor & Delivery Tracheostomy Care

Medicine ‐ Ambulatory Need Recent Training Exp.

Venipuncture

Medicine – Inpatient

Mental Retardation Circulatory

List other skills or areas worked Neurology Digestive

Newborn Nursery Musculoskeletal

Oncology – Ambulatory Neurological

Oncology – Inpatient Obstetrical

O.R. Oral

Orthopedics Pediatric

Psychiatric

Renal

Reproductive

Respiratory

Authorization and Consent to Release Information

The Specialty Nurse Co. values high quality care for all our clients, and because we provide services in our client’s homes, it is absolutely essential that we maintain high standards for employees we recruit. In order to achieve that goal, The Specialty Nurse Co. utilizes the service of a company that performs pre-employment screening. I have never been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement of this effect obtained at this time of application. Additionally, I herby state that the information given by me in my employment application is true, correct and complete in all respects. I, understand that in consideration of my application, an investigation and verification may be conducted of my past employment, education and activities. I therefore authorize pat employers, personal references, and any other persons whom I am acquainted to answer all questions asked concerning my previous employment records, ability, educational background, military service records, medical history, criminal records, credit history, driving records, charter and reputation. I release all persons including past employers, credit bureaus and government agencies from all and all liabilities or furnished in compliance with the Fair Credit Report Act. In consideration of my application for employment, I authorize The Specialty Nurse Co. and/or its agents to conduct such an investigation, and release the company named above, including its officers, employees or agents and representatives from all liability or responsibility for this investigation. I understand that the information requested below regarding sex, race and date of birth are for the sole purpose of gathering information accurately and will not be used to discriminate against me in violation of any law. I understand that a consumer report may be requested or an investigation conducted. I further understand that if employment is denied in whole or in part because of information obtained from a consumer-reporting agency, I have the right to make a written request within a responsible period of time to receive information about the scope and nature of the investigation. A telephone facsimile, photographic or digitally produced copy of this authorization shall be valid as the original. I herby authorize and grant permission to The Specialty Nurse Co. is contracted or affiliated. Applicants Full Legal Name (Print) Date of Birth Social Security Number Drivers License Number & State Gender Race Current Address City State Zip Signature Date

Tuberculosis Descriptions and Checklist for Signature

TB Description and Checklist Tuberculosis is caused by the microorganism, Mycobacterium tuberculosis. The germ is transmitted in the air from one person to another, and through cows with non-pasteurized milk. Frequently, onset of clinical symptoms and progression of the disease can be tied to impairment or damage to the immune system. Signs and Symptoms of Tuberculosis (TB) Most commonly, early stages of tuberculosis have no symptoms. Sometimes, the person infected may have cough and fever. As the disease progresses, it produces more apparent symptoms. These include fever, weight loss, chronic fatigue and heavy sweating, especially at night. As tuberculosis worsens in the lungs, it produces sputum that becomes progressively bloody, yellow, thick or gray. There is often chest pain or discomfort and shortness of breath. Cloudy or reddish urine can occur. Other symptoms can develop when other organ systems become involved, such as the brain. Lumps may develop in the nasal cavity. Pott’s disease or tuberculosis of the spine is associated with back pain, fever, chills and night sweats. Varying degrees of weakness or numbness may occur in the legs or around the genitals and rectum. List of Symptoms: Reoccurring fever and chills Ongoing cough Weight loss Chronic fatigue Heavy sweating Chest pain Shortness of breath Cloudy or reddish urine Lumps in my nasal cavity By signing this document I verify I have NOT had signs or symptoms of tuberculosis (see list above) since my most recent chest x-ray, and that I have not knowingly been exposed to tuberculosis or hepatitis. I agree to notify PQSI immediately if I think I’ve been exposed to T.B. _____________________ ______________________ ___________ Employee Name (printed) Employee Signature Date (See Next Page )

Hepatitis Description and Checklist for Signature

Hepatitis B is a viral infection of the liver contracted by coming into contact with an infected person's blood or bodily fluids. Less than half of those with short-term (acute) Hepatitis B infections have symptoms. Symptoms include:

Jaundice (the skin and whites of the eyes appear yellow). Although jaundice is the defining sign of hepatitis B, it does not occur in most cases. Jaundice usually appears after other symptoms have started to go away.

Extreme tiredness (fatigue). Mild fever. Headache. Loss of appetite. Nausea. Vomiting. Constant discomfort on the right side of the abdomen under the rib cage,

where the liver is located. In most people, the discomfort is made worse when their bodies are jarred or if they overwork themselves.

Diarrhea or constipation. Muscle aches. Joint pain. Skin rash.

Work-related exposure. People who handle blood or instruments used to draw blood may become infected with the virus. Health care workers are at risk of becoming infected with the virus if they are accidentally stuck with a used needle or other sharp instrument infected with an infected person's blood, or if blood splashes onto an exposed surface, such as the eyes, mouth, or a cut in the skin. Grooming items such as razors and toothbrushes can spread HBV if they carry blood from a person who is infected. If you have come in contact with an infected person, you are required to notify us immediately of such exposure. Immediate action must be taken to stop the spread of the Hepatitis B virus. You have the option, if exposed, to receive the Hepatitis B vaccine. By signing below, you acknowledge that you currently have no signs or symptoms of Hepatitis B and agree to adhere to our policy of immediate notification if you think you've been exposed.

_____________________ ______________________ ____________ Employee Name (printed) Employee Signature Date

Documents

Name, Address, Contact Information