Employment Form




Personal Information

Name
Address

Home Tel #:
Cell #:
County
Email Address

EMPLOYMENT DESIRED

Position Applied For:
 Pediatric RN Pediatric LPN
Hours Desired:
Please indicate Days and Hours you are available for work (BE SPECIFIC)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Days
Evenings
Nights
How far are you willing to travel ?
Do you have a car available? Yes No
Are you available on holidays?  Yes No
Are you 18 years of age or older? Yes No
Are you employed now? Yes No
May we contact your present employer? Yes No
Have you ever applied to SHCA before? Yes No
Have you ever worked for SHCA before? Yes No
What professional licenses do you have? RN LPN

EDUCATION

Name of School
Address
Completed
Type of Degree or Certificate Received
College
 Yes No
Other(please specify)
 Yes No
Professional organization memberships, honors received, volunteer or community, service or other qualifications you have which you
feel are related to the position for which you are applying:

EMPLOYMENT HISTORY

List below your work experience, starting with your present or last place of employment

Dates of Employment
Name and Address of Employer
Name and Phone Number of Supervisor
Your Position and Pay Rate
Reason for Leaving
From:
To:
From:
To:
From:
To:
Have you ever been convicted of a crime? Yes No
If Yes, for what/when/where?
Conviction of a criminal offense will not necessarily preclude your employment. Use this space to give us further information which will assist us in placing you, including at least two personal referenced not related to you, whom you have known at least one year.
How did you learn about this opening?
 Newspaper Advertisement School Brochure Yellow Pages Advertising Direct Mailing Internet Other

SKILLED NURSING CLINICAL COMPETENCY SELF ASSESSMENT FORM

Field Nurse’s Name:
Please evaluate your skills from 0–5, where 0 means no experience and 5 means very experienced.
Skill
Describe extent of your knowledge
Pediatric Assessment
Neonatal Assessment
Medication Admin. PO
Auscultation of breath sounds
Auscultation of bowel sounds
Injection administration
Gastrostomy care
Feeding pump use
Insertion of GT
Insertion of NGT
NGT placement check
Admin. of GT/NGT feeding
Chest PT
Admin. of neb. Treatment
Trach Care Cuffed/Uncuffed
Trach tube change
Suction: oral/nasal/trach
Mist collar use
Ventilator care: adult/peds
Vent circuit changes
BIPAP
CPAP
Coffalator use
Use of O2
Pulse oximeter use
Apena monitor use
IV site care
Administration of IV meds
Ambu bag use
Emergency trach change
Sterile dressing change
Use of Hoyer lift/other lift
Care of quad/paraplegic
Catheter car/insertion
Colostomy care
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