Texas Nurse Connection, Ltd



Texas Nurse Connection, Ltd

3385 North 3rd, Suite 1, Abilene, Texas 79603

RN / LVN

Required Documentation / Application Procedure Checklist

Each applicant must have graduated from an accredited school of nursing and have a current, active state license and CPR card.

The documentation below must be in your file prior to employment

Page 1 Required Documentation Application Checklist

Page 2 Job Application

Page 3 Employment Experience

Page 4 License, Certifications, and Immunizations Copies of Original Documents

Page 5 Authorization to Release Information, Background, Confidentiality Statement. Signature and Date Required

Page 6 Skills Checklist

Page 7 Skills Checklist

Page 8 Skills Checklist

Page 9 RN / LVN Job Description Signature and Date Required

Page 10 OSHA Compliance, Hep-B, Varicella, HIPAA Signature and Date Required

Page 11 Professional Reference Check Signature and Date Required

Page 12 Professional Reference Check Signature and Date Required

Page 13 Handbook/Guide to Health and Safety, Job Fulfillment and Timecard Acknowledgement Signature and Date Required

Page 14 Affirmative Action Form Signature and Date Required

Page 15 Disclosure to Employment Application Signature and Date Required

Page 16 Orientation Checklist Signature and Date Required

Attachments: I-9 Signature, Date

Copies of 2 Forms of Identification (Driver’s License, SSC)

W-4 Signature and Date Required

Direct Deposit Form Signature and Date Required

When Texas Nurse Connection, Ltd. receives your application the Staff Coordinator will review all information you have provided. Depending on your specialty and experience you will be asked to take one or more of the following competency tests. Please check the test or tests that apply to your specialty:

Clinic / LTC Competency Test

Psych Competency Test

Medical / Surgical Competency Test

Emergency Department Competency Test

Intensive Care Unit Competency Test

Labor and Delivery Competency Test

Pediatric Competency Test

Operating Room Competency Test

Ethics, Legal Issues, and Compliance Competency Test

Leadership / Management Competency Test

HIPAA (All Discipline Required To Take Test)

Population Served Competency Test (Required for all RN’s and LVN’s)

Thank you for taking the time to complete this application. Please fax to our toll free fax: 1-866-TNCFAXS or mail to the address listed below.

Texas Nurse Connection, Ltd. • 3385 North 3rd, Suite 1 • Abilene, TX 79603

Telephone (325) 670-0090 • Toll Free 1-866-WORKTNC • Fax (325) 670-0094 • Toll Free 1-866-TNCFAX

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Texas Nurse Connection, Ltd

3385 North 3rd, Suite 1, Abilene, Texas 79603

JOB APPLICATION

RN LVN

Please Print Clearly Black Ink.

|Texas Nurse Connection, Ltd does not discriminate in respect to hiring, firing, compensation, and all other terms and conditions of |

|privileges of employment on the basis of race, color, national origin, ancestry, sex, age, pregnancy, or related medical conditions, |

|marital status, religious creed, physical handicap not related to the ability to do the job, or a medical condition related to cancer or |

|age. |

|Date: |  |  |Social Security Number: |  |  |  |

|Name: |LAST |  |  |FIRST |  |  |MIDDLE |

|Drivers License Number: |STATE |  |NUMBER |  |  |  |

|E-Mail Address: |  |  |  |  |  |  |  |

Are you legally eligible for employment in the United States? Yes No

Have you ever been convicted of a felony or received a deferred adjudication for pleading no contest or guilty within the past seven years? Yes No

If yes, please explain:

List any limitations you have that require special accommodations:

How were you referred to us? Newspaper Radio Television Phone Book

Billboard Family/Friend Texas Workforce Commission Other: ____________

Have you ever worked for a staffing agency? Yes No If yes, company?

To which facilities did the service (s) send you?

EDUCATION

|  |  |Name and Location |  |Date of Graduation |Type of Degree |

|Nursing Education |  |  |  |  |  |  |  |

|College / University |  |  |  |  |  |  |  |

|High School / GED |  |  |  |  |  |  |  |

|Other |  |  |  |  |  |

|HOSPITAL/FACILITY |  |  |  |  |  |  |

|ADDRESS |  |  |  |CITY |STATE |ZIP |

|PHONE |  |FAX |  |  |OTHER |  |

|DATES OF EMPLOYMENT |FROM |  |  |TO |  |

|SUPERVISOR |NAME |  |  |TITLE |  |

|JOB TITLE & UNIT WORKED |  |  |  |  |  |

|Charge Experience? □ Yes. □ No. |May We Contact This Employer? □ Yes. □ No. |

|REASON FOR LEAVING |  |  |  |  |  |

| | | | | | | |

|EMPLOYER (2) |  |  |  |  |  |

|HOSPITAL/FACILITY |  |  |  |  |  |  |

|ADDRESS |  |  |  |CITY |STATE |ZIP |

|PHONE |  |FAX |  |  |OTHER |  |

|DATES OF EMPLOYMENT |FROM |  |  |TO |  |

|SUPERVISOR |NAME |  |  |TITLE |  |

|JOB TITLE & UNIT WORKED |  |  |  |  |  |

|Charge Experience? □ Yes. □ No. |May We Contact This Employer? □ Yes. □ No. |

|REASON FOR LEAVING |  |  |  |  |  |

| | | | | | | |

|EMPLOYER (3) |  |  |  |  |  |

|HOSPITAL/FACILITY |  |  |  |  |  |  |

|ADDRESS |  |  |  |CITY |STATE |ZIP |

|PHONE |  |FAX |  |  |OTHER |  |

|DATES OF EMPLOYMENT |FROM |  |  |TO |  |

|SUPERVISOR |NAME |  |  |TITLE |  |

|JOB TITLE & UNIT WORKED |  |  |  |  |  |

|Charge Experience? □ Yes. □ No. |May We Contact This Employer? □ Yes. □ No. |

|REASON FOR LEAVING |  |  |  |  |  |

Texas Nurse Connection, Ltd. • 3385 North 3rd, Suite 1 • Abilene, TX 79603

Telephone (325) 670-0090 • Toll Free 1-866-WORKTNC • Fax (325) 670-0094 • Toll Free 1-866-TNCFAXS

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Texas Nurse Connection, Ltd

3385 North 3rd, Suite 1, Abilene, Texas 79603

LICENSE, CERTIFICATIONS, AND IMMUNIZATIONS

Classification: RN LVN

|LICENSE NUMBER |  |  |STATE |  |  |EXP|  |

| | | | | | |IRA| |

| | | | | | |TIO| |

| | | | | | |N | |

| | | | | | |DAT| |

| | | | | | |E | |

|CHEST X-RAY |  |DATE RECEIVED |  |  |RESULTS |  |  |

|VARICELLA |  |DATE RECEIVED |  |  |RESULTS |  |  |

SPECIALIZATION

| Clinics/Dr. Offices | M/S | ICU/CCU | Pediatrics |

| Home Health | ER/Trauma | PCU | OB/GYN |

| Long Term Care | Telemetry | NICU | Mother/Baby |

| Psych | Step-Down | PICU | Labor/Delivery |

| Rehab | Oncology | CVICU | Post Partum |

| Dialysis | OR | Recovery | New Born |

| Other: ______________________________ | Other: _______________________________ |

|Area you have performed proficiently in for at least one year: |  |  |  |

|AREA/UNIT |  |  |  |  |  |YEARS OF EXPERIENCE |  |

|Other specialty areas you have performed in and could float to: |  |  |  |

|AREA/UNIT |  |  |  |  |  |YEARS OF EXPERIENCE |  |

|AREA/UNIT |  |  |  |  |  |YEARS OF EXPERIENCE |  |

|AREA/UNIT |  |  |  |  |  |YEARS OF EXPERIENCE |  |

AVAILABILITY

| | SUN | MON | TUES | WED | THUR | FRI | SAT |

| | AM Shifts | PM Shifts | Either | | |

| | PRN | Contract | Temp to Perm | Permanent |

Texas Nurse Connection, Ltd. • 3385 North 3rd, Suite 1 • Abilene, TX 79603

Telephone (325) 670-0090 • Toll Free 1-866-WORKTNC • Fax (325) 670-0094 • Toll Free 1-866-TNCFAXS

4

Texas Nurse Connection, Ltd

3385 North 3rd, Suite 1, Abilene, Texas 79603

EMPLOYEE AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION ON EMPLOYMENT FILE, BACKGROUND CHECK, FINGERPRINTING, MEDICAL RECORDS, RANDOM DRUG SCREENING, AND CLIENT, PATIENT, AND EMPLOYER CONFIDENTIALITY STATEMENT.

By affixing my signature hereunder, I authorize Texas Nurse Connection, Ltd to release any and all confidential employment, background check and medical information contained in my employment file to any medical facility or entity with whom Texas Nurse Connection, Ltd has a staffing agreement, and to any other governmental or regulatory agency at such agency’s request. For all other purposes, Texas Nurse Connection, Ltd shall keep my employment records confidential and shall advise any medical facility or other entity to whom records have been provided to also keep such records confidential. I hereby waive any privilege I may have to this information with respect to its release to Texas Nurse Connection, Ltd.

Regarding the MEDICAL RECORDS, BACKGROUND CHECKS AND FINGERPRINTING RELEASE, this internal information is confidential and we will instruct our client facilities or other entities to treat the information provided confidentially as well.

Regarding the DRUG SCREENING RELEASE, I voluntarily consent to a urine, blood or breathe sample for the purposes of an alcohol, drug, intoxicant, or substance abuse screening test. Furthermore, I voluntarily consent to the release of the test results to Texas Nurse Connection, Ltd, or its designee, for purposes of determining the fitness for employment or continued employment.

Regarding the CLIENT, PATIENT, AND EMPLOYER’S CONFIDENTIALITY STATEMENT, I voluntarily consent that all information will be kept in strict confidence and will not be shared with any individual outside of those working for Texas Nurse Connection, Ltd. Confidential information is the property of clients, patients, or Texas Nurse Connection, Ltd.

My signature hereunder further indicates that I have read the EMPLOYEE AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION ON EMPLOYMENT FILE, BACKGROUND CHECK, FINGERPRINTING, MEDICAL RECORDS, RANDOM DRUG SCREENING, AND CLIENT, PATIENT, AND EMPLOYERS CONFIDENTIALITY STATEMENT in its entirety and understand its contents.

I certify that the facts contained in this application are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. As a condition of employment, I understand and agree to submit to a drug screening and background investigation, and if accepted for employment, shall and do hereby consent to random drug or screening if assigned to work in a patient care position. I authorize the employer to investigate any and all statements contained herein and request the persons, firms, and/or corporations named above to answer any and all questions relating to this application. I release all parties from all liability the employer and any person, firm or corporation who provides information concerning my prior education, employment or character.

I understand that my employment is an employment at will and may be terminated at any time without prior notice.

Date ____________________ Signature__________________________________________________________

|Texas Nurse Connection, Ltd does not discriminate in respect to hiring, firing, compensation, and all other terms and conditions of |

|privileges of employment on the basis of race, color, national origin, ancestry, sex, age, pregnancy, or related medical conditions, |

|marital status, religious creed, physical handicap not related to the ability to do the job, or a medical condition related to cancer or |

|age. |

Texas Nurse Connection, Ltd. • 3385 North 3rd, Suite 1 • Abilene, TX 79603

Telephone (325) 670-0090 • Toll Free 1-866-WORKTNC • Fax (325) 670-0094 • Toll Free 1-866-TNCFAXS

5

Texas Nurse Connection, Ltd

3385 North 3rd, Suite 1, Abilene, Texas 79603

RN & LVN Self Assessed Skills Checklist

Name: ___________________________________________________ Date: _______________________

1 = No Experience 2 = Limited Experience 3 = Moderate Experience 4 = Proficient

|SPECIMEN COLLECTION |1 |

|Employee Handbook: Policies & Procedures | |

|Texas Nurse Connection, Ltd. Mission and Goals | |

|Timekeeping, Payroll, and Pay Periods | |

|Attendance & Punctuality | |

|Reporting Common Problems | |

|Grievance Process | |

|Sentinel Events | |

|Employee Guide to Health & Safety: Policies & Procedures | |

|Infection Control, Including CDC Hand Hygiene Guidelines | |

|Universal Precautions | |

|General Safety While Working | |

|Fire Safety & Prevention | |

|Safety With Hazardous/Dangerous Materials | |

|Patient Safety, Including National Patient Safety Goals | |

|Cultural Diversity & Sensitivity | |

|Confidentiality, including HIPAA: Awareness & Training | |

|Testing: Knowledge & Competency | |

The Employee Handbook and the Employee Guide to Health & Safety Book describe important information regarding Texas Nurse Connection, Ltd, and I understand that I should consult the Human Resources Department regarding any questions not answered in these books. I have entered into my employment relationship with Texas Nurse Connection, Ltd voluntarily and acknowledge that there is no specified length of employment. Accordingly, either I or Texas Nurse Connection, Ltd can terminate the relationship at will, with or without cause at any time, so long as there is no violation of applicable federal or state law.

Since the information, policies, and benefits described here are necessarily subject to change. I acknowledge that revisions to the Employee Handbook and Employee Guide to Health & Safety Book may occur, except to Texas Nurse Connection, Ltd policy of employment at will. All such changes will be communicated through official notices, and I understand that the revised information will supersede, modify or eliminate existing policies. Only the CEO of Texas Nurse Connection, Ltd. has the ability to adopt any revisions to the policies in the aforementioned books.

By signing below, I acknowledge that I have received the Employee Handbook, Employee Guide to Health and Safety book, an overview of the Texas Nurse Connection, Ltd policies and procedures listed above and have completed the necessary testing materials to begin my employment.

Employee Signature: Date:

TNC Representative: Date:

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