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Personal Information

Name
Address

Home Tel #:
Cell #:
County
Email Address

EMPLOYMENT DESIRED

Position Applied For:
Pediatric RNPediatric 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?YesNo
Are you available on holidays? YesNo
Which holidays are you unable to work?
Are you 18 years of age or older?YesNo
Are you employed now?YesNo
May we contact your present employer?YesNo
Date you can start:
Have you ever applied to SHCA before?YesNo
When?
Have you ever worked for SHCA before?YesNo
Where?
Supervisor:
Reason for Leaving:
What professional licenses do you have?RNLPN
The License-issuing authority or board:
License #:
Date of Expiration:
Do you have malpractice insurance? YesNo
If “Yes” Malpractice Carrier Information (name & address)

EDUCATION

Name of School
Address
Completed
Type of Degree or Certificate Received
College
YesNo
Other(please specify)
YesNo
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
Reason for Leaving
From:
To:
From:
To:
From:
To:
How did you learn about this opening?
Newspaper AdvertisementSchoolBrochureYellow PagesAdvertising Direct MailingInternetOther

SKILLED NURSING CLINICAL COMPETENCY SELF ASSESSMENT FORM

Field Nurse’s Name:
RNLPN
Date:
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
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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