subject_line
Basic Information
First Name
*
Last Name
*
Email Address
*
Cell Phone
*
Profession
*
CRNA
MD
DO
Medical Technologist
NP
OT
PA
Pharmacist
PT
PTA
Respiratory
RN
SLP
Surgical Tech
Work History Record
Facility / Employer Name
*
Is this a teaching facility?
*
Yes
No
# of Beds at Facility
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City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Position Held
*
Hours Worked
*
Full Time
Part Time
Per Diem
Position Type
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Staff
Travel
Per Diem
Other
Name of Agency
*
Start Date
*
+
End Date (if applicable)
+
Reason for Leaving
*
still employed
career advancement
relocated
assignment completed
to travel
lay off
personal reason
medical reason
financial
terminated
other
Reason for Termination
*
0/200 characters
Unit Specialty
*
# of Beds in Unit
*
Patient Load
*
Did you serve as a charge nurse?
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Yes
No
Did you float to other units?
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Yes
No
Description of float duties.
*
0/75 characters
Technologies Utilized
0/100 characters
Would you like to add another work history record?
*
Yes
No
Do you have lapses (breaks) in your work history over the past seven years that lasted for more than one month (30 days)?
If so, we will need you to identify and explain these lapses as well.
*
Yes
No