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Personal Information
First Name
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Address
Apartment, Floor, Suite #
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*
Home Tel #:
Cell #:
Email Address
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Social Security Number
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What languages other than English do you speak?
Employment Desired
Position Applied For:
Pediatric RN
Pediatric LPN
RN Care Manager
Office Staff
Other
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Hours Desired
*
Please indicate Days & Hours you are available for work (BE SPECIFIC). E.g: Monday: 8am – 10am
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Evenings
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Nights
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How far are you willing to travel?
Do you have a car available?
Yes
No
Are you available on holidays?
*
Yes
No
Which holidays are you unable to work?
Are you 18 years old or older?
*
Yes
No
Are you employed now?
*
Yes
No
May we contact your present employer?
Yes
No
Date you can start:
Date Format: MM slash DD slash YYYY
Have you ever applied to SHCA before?
Yes
No
When?
Have you ever worked for SHCA before?
Yes
No
Where?
Supervisor
Reason for Leaving:
What professional licenses do you have?
RN
LPN
The License-issuing authority or board
License/Certificate Number:
Date of Expiration:
Date Format: MM slash DD slash YYYY
CPR Certificate
Yes
No
Date of Expiration
Date Format: MM slash DD slash YYYY
Do you have malpractice insurance?
Yes
No
If "Yes", Malpractice Insurance Carrier Information (name and address)
100
Malpractice insurance
Drop files here or
Education
College
Name of School
Address
Completed
Yes
No
Type of Degree or Certificate Received
Other (Specify)
Name of School
Address
Completed
Yes
No
Type of Degree or Certificate Received
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
From
To
Name & Address of Employer
Name & Phone of Supervidor
Your Position
Reason for Leaving
From
To
Name & Address of Employer
Name & Phone of Supervisor
Your Position
Reason for Leaving
From
To
Name & Address of Employer
Name & Phone of Supervisor
Your Position
Reason for Leaving
How did you learn about this opening?
*
Newspaper Advertisement
School
Brochure
Advertising Direct Mailing
Internet
Other
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Upload your Resume
Drop files here or
Skilled Nursing Clinical Competency Self Assesment Form
Field's Nurse's Name:
RN
LPN
Date:
Date Format: MM slash DD slash YYYY
Please evaluate your skills from 0–5, where 0 means no experience and 5 means very experienced.
Skill
Self Evaluation
Describe extent of your knowledge
Pediatric Assessment
Pediatric Assessment
0
1
2
3
4
5
Neonatal Assessment
Neonatal Assessment
0
1
2
3
4
5
Medication Admin. PO
Medication Admin. PO
0
1
2
3
4
5
Ausculation of breath sounds
Ausculation of breath sounds
0
1
2
3
4
5
Auscultation of bowel sounds
Auscultation of bowel sounds
0
1
2
3
4
5
Injection administration
Injection administration
0
1
2
3
4
5
Gastrostomy care
Gastrostomy care
0
1
2
3
4
5
Feeding pump use
Feeding pump use
0
1
2
3
4
5
Insertion of GT
Insertion of GT
0
1
2
3
4
5
Insertion of NGT
Insertion of NGT
0
1
2
3
4
5
NGT placement check
NGT placement check
0
1
2
3
4
5
Admin. of GT/NGT feeding
Admin. of GT/NGT feeding
0
1
2
3
4
5
Chest PT
Chest PT
0
1
2
3
4
5
Admin. of neb. Treatment
Admin. of neb. Treatment
0
1
2
3
4
5
Trach Care Cuffed/Uncuffed
Trach Care Cuffed/Uncuffed
0
1
2
3
4
5
Trach tube change
Trach tube change
0
1
2
3
4
5
Suction: oral/nasal/trach
Suction: oral/nasal/trach
0
1
2
3
4
5
Mist collar use
Mist collar use
0
1
2
3
4
5
Ventilator care: adult/peds
Ventilator care: adult/peds
0
1
2
3
4
5
Vent circuit changes
Vent circuit changes
0
1
2
3
4
5
BIPAP
BIPAP
0
1
2
3
4
5
CPAP
CPAP
0
1
2
3
4
5
Coffalator use
Coffalator use
0
1
2
3
4
5
Use of O2
Use of O2
0
1
2
3
4
5
Pulse oximeter use
Pulse oximeter use
0
1
2
3
4
5
Apena Monitor Use
Apena Monitor Use
0
1
2
3
4
5
IV site care
IV site care
0
1
2
3
4
5
Administration of IV meds
Administration of IV meds
0
1
2
3
4
5
Ambu bag use
Ambu bag use
0
1
2
3
4
5
Emergency trach change
Emergency Trach Change
0
1
2
3
4
5
Sterile dressing change
Sterile dressing change
0
1
2
3
4
5
Use of Hoyer lift/other lift
Use of Hoyer lift/other lift
0
1
2
3
4
5
Care of quad/paraplegic
Care of quad/paraplegic
0
1
2
3
4
5
Catheter car/insertion
Catheter car/insertion
0
1
2
3
4
5
Colostomy care
Colostomy care
0
1
2
3
4
5
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