Pre-Employment Check List - Pulse Medical Staffing · 620 N. Trade Winds Parkway Suite A Columbia, MO 65202 Toll Free Phone & Fax 877.883.8677 Pre-Employment Check List Please provide

620 N. Trade Winds Parkway Suite A Columbia, MO 65202 Toll Free Phone & Fax 877.883.8677

Pre-Employment Check List

Please provide clear copies of the following along with your completed application. Please complete our application entirely, incomplete applications will delay

processing.

□ Drivers License □ Social Security Card □ Current Nursing License □ Any Certifications (if applicable) □ Current CPR □ Current ACLS (if applicable) Complete the following forms (included in this application packet).

□ Application □ Reference Check #1 □ Reference Check #2 □ Skills Checklist □ Testing as required □ Health Statement/Physical □ Proof of Vaccination History □ HIPAA Statement □ I-9 Documentation

Post Hire – Check List

□ Federal W-4 □ Missouri W-4 □ Direct Deposit Form □ Payroll Input Form

Thank You for applying with us. Please feel free to call us anytime if you have questions.

1 620 N. Trade Winds Parkway, Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677

Name:

Please indicate 1, 2, 3, or 4 in boxes below using the following rankings: 1 = Clinicals Only 2 = Some Experience 3 = Experienced 4 = Can Perform Task Independently

UNIT / SKILLS Exp UNIT / SKILLS Exp

GENERAL ASSESSMENT

Admission Procedure Normal vs. Abnormal Vitals

Gathering Prenatal History Pelvic Exam

Initial Physical Assessment S&S of Bleeding

Knowledge of Obstetric Terminology S&S of Ruptured Membranes Fern Testing

Lab Value Interpretation Lab Value Interpretation

INTRAPARTUM CARE

Assessment of: Fetal Malpresentation

(1) Cervical Dilation Fetal Positioning

(2) Effacement Intrapartum Deaths

Fetal Malpositioning Normal Stages of Labor

DELIVERY

Assist with Forceps Delivery Circulate

(1) Type of Forceps: Scrub

Assist with Normal Vaginal Delivery Unassisted Delivery

C-sections: Vacuum Extraction Delivery

POSTPARTUM CARE

Assessment of: (9) Vaginal Changes

(1) Bladder Distension (10) Vitals (normal ranges)

(2) Bowel Function Breast Care

(3) Caesarian Incision Nutritional Considerations for Breast Feeding Mothers

(4) Episiotomy Proper Breast Feeding Techniques and Various Positions

(5) Fundus Consistency Care of Recovering Patient

(6) Homan Sign (1) Epidural Anesthesia

(7) Lochia (2) General Anesthesia

(8) Psychological Status Grieving Mothers (loss of child during birth)

Pain Management

Care of patients with:

D.I.C. Hemolytic Anemias

Gestational Induced Diabetes Malpresentations

Gestational Induced Hypertension Preterm Labor

HIV Disease (1) Assessment of Psychological

Diabetes (2) Considerations of

HELLP Syndrome Rh Incompatibility

Infectious Disease Sickle Cell

Meconium Staining Newborns

Multiple Gestations (1) A.R.D.S.

Placenta Previa or Abruptio Placenta (2) Congenital Anomalies

Preruptured Membranes (3) Cord Prolapse

Preeclampsia/Eclampsia (4) Malformations

(5) Still Births

SKILLS CHECKLIST LABOR/DELIVERY – MOTHER/BABY


LABOR/DELIVERY – MOTHER/BABY SKILLS CHECKLIST (continued)


COMPETENCE IN THE FOLLOWING:

Ability to Perform 1 Person Rescue Infant Warmer Usage

(1) CPR - Infant/Child Intubations

(2) CPR - Adult (1) Assisting in Intubations

Ambu Bag Technique (2) Knowledge of ETT Sizes

(1) Adult Universal Isolation Procedures/Precautions

(2) Newborn Isolette Usage

Apnea Monitor Usage Nebulizer Usage

Assist with Amniocentesis NST/CST

Basic EKG Interpretation Oxygen Administration

Use of Blood Pressure Monitor (1) Via Nasal Cannula

Use of Cardiac Monitor (2) Face Mask

Use of Doppler Phototherapy Treatment

Use of Fetal Monitor Sterile Dressing Changes

(1) Normal Ranges Suctioning

(2) Internal Monitor Lead Connection/Calibration (1) Bulb Syringe

(3) Proper Placements (2) Oral

Catheterization (urinary) of: (3) Endotracheal

(1) Female Teaching Infant/Child Safety

(2) Newborn Weighing

Determining Proper Catheter Size Infants

Hyper-Amniotic Fluid Drainage Diapers

Hypothermic Blanket Usage

IV THERAPY

Insertion of Peripheral Line (2) Care of Insertion Site

(1) Newborn Dressing Changes

(2) Newborn Scalp Record Keeping

(3) Adult Hang IV Piggybacks

Administration of IV Meds Use of Bretols for Newborns

Blood/Blood Products Administration (1) Other

Calculate Rates Infusion Pump

(1) Adults (1) IVAC

(2) Newborns (2) IMED

Care of Peripheral Lines S&S of Infection

(1) Infusion Procedures S&S of Infiltration

NEWBORN CARE SKILLS

Apgar Scoring Cord Care

Assessment of Normal Newborn Feeding Techniques for Newborn

(1) Head Circumference (1) Bulb Syringe

(2) Height/Weight (2) Preemie nipple

(3) Vital Signs (3) Med Dropper

Bathing Newborns (4) NG Tube Insertion

Circumcision Care I.D. of Newborn

(1) Assist with Circumcision (1) Footprints

(2) Tri-Band System Policy


LABOR/DELIVERY – MOTHER/BABY SKILLS CHECKLIST (continued)


MEDICATION ADMINISTRATION

Epidurals Pain Management & Comfort Measures

(1) Assist with Lumbar Puncture (1) In Relation to Fetal Positioning

Injections Paracervical Blocks

(1) Preparation of Meds/Syringe Use of:

(2) Record Keeping (1) IV Valium

(3) Site Selection (2) IV Narcan

(4) SQ (3) Anti-tocolytics

(5) IM (4) Insulin Drops

Indomethacin (5) Prostaglandins

Insulin Ritodrine

Magnesium Sulfate Terbutaline

Procardia

SPECIMEN COLLECTION

Arterial Blood Gas Draw Interpretation Venipuncture

Blood Culture (1) Adult

Capillary Draw (2) Newborn

Heelstick of Newborn Stool

ADDITIONAL NURSING RESPONSIBILITIES

Discharge - Planning/Teaching SOAP Charting

Knowledge of Unit Doses Charge Nurse Responsibilities

Legal Aspects of Documentation Primary Nurse Responsibilities

Problem Oriented Medical Records Team Leading

The information I have given is true and accurate to the best of my knowledge. I hereby authorize

Pulse Medical Staffing to release this Skills Checklist to facilities/clients of Pulse Medical Staffing in

relation to consideration of my Employment with those facilities/clients.

Signature:

Date:

620 N. Trade Winds Parkway Suite A, Columbia, MO 65201 Toll Free Phone & Fax 877.883.8677

PROFESSIONAL REFERENCE CHECK

I, _________________________________________________________

(Employee Name)

Authorize Pulse Medical Staffing to request any information concerning my qualifications, performance and work ethics. Further I hereby release the company or person completing this form from any and all liability in supplying the requested information.

Signature:

Date:

REFERENCE INFORMATION (Applicant, please complete)

Company: Reference Name:

Position Held: Reference Phone:

Start Date: Reference Address:

End Date: Reason for Leaving:

Applicant – DO NOT WRITE BELOW THIS LINE

---------------------------------------------------------------------------------------------------------------- Would you rehire this person? Yes No If no, please explain: ______________________________________________________________________ Please rate the applicant on a scale from 1 to 10 (10 being the highest):

Attribute/Quality 1 2 3 4 5 6 7 8 9 10 Additional Comments

Dependability

Flexibility

Team Work

Professionalism

Interaction with Co-Workers

Interaction with Supervisors

Joint Commission Compliance

HIPPA Compliance

Policies/Procedures

Appearance

What is your affiliation to the above applicant? Supervisor / Former Supervisor Coworker / Former Coworker

Human Resources Other: ___________________

Completed by:

Signature:

Date:

Title:


PROFESSIONAL REFERENCE CHECK

I, _________________________________________________________

(Employee Name)

Authorize Pulse Medical Staffing to request any information concerning my qualifications, performance and work ethics. Further I hereby release the company or person completing this form from any and all liability in supplying the requested information.

Signature:

Date:

REFERENCE INFORMATION (Applicant, please complete)

Company: Reference Name:

Position Held: Reference Phone:

Start Date: Reference Address:

End Date: Reason for Leaving:


---------------------------------------------------------------------------------------------------------------- Would you rehire this person? Yes No If no, please explain: ______________________________________________________________________ Please rate the applicant on a scale from 1 to 10 (10 being the highest):

Attribute/Quality 1 2 3 4 5 6 7 8 9 10 Additional Comments

Dependability

Flexibility

Team Work

Professionalism

Interaction with Co-Workers

Interaction with Supervisors

Joint Commission Compliance

HIPPA Compliance

Policies/Procedures

Appearance

What is your affiliation to the above applicant? Supervisor / Former Supervisor Coworker / Former Coworker

Human Resources Other: ____________________

Completed by:

Signature:

Date:

Title:


Employee Health Statement

Employee Name: __________________________________________________________ Date of Birth: _________________________________

I authorize my healthcare provider to release my health information to Pulse Medical

Staffing. I understand that this information is disseminated to the facilities as part of my

placement as required by facility and JCAHCO.

Employee Signature: _______________________________________________________ Date: _______________________________________

Physician’s Office No. ______________________________________________________ Physician’s Fax No._____________________________


--------------------------------------------------------------------------------------------------------------------------------------------------------------

The above patient has been seen by me and has been found to be in good mental and

physical health, free of communicable disease, and able to function in the healthcare

profession without any physical limitations.

Today’s Date: ________________________________________

Date of last visit: ______________________________________

Physician’s Printed Name: ___________________________________________________ Physician’s Signature: ______________________________________________


Immunization’s Statement

Employee Name: _________________________________________________________ Date of Birth: _________________________________

OSHA requires that all healthcare workers at risk of acquiring the HBV be vaccinated. By signing below

I certify that I have the general education regarding exposure to the blood borne pathogens as

required by OSHA. I further understand that I should follow each facilities training and policy

regarding blood and body fluids.

I hereby verify that these statements are truthful and accurate.

Employee Signature: _______________________________________________________Date: ________________________________________

Hepatitis B

□ I decline the vaccine due to I have received the series.

□ I have completed the vaccine series on the following date: ___________________________

Tuberculosis

Last TB skin test (PPD) Date’s: 1) _______________________ 2) _____________________________

If positive TB skin test (PPD) Date: _________________________________Last chest X-ray Date: __________________________

MMR Vaccination Date’s: 1) ___________________________ 2) _____________________________

If positive/exposed Date: _______________________________

Varicella

Vaccination Date’s: 1) ___________________________ 2) _____________________________

If positive/exposed Date: _______________________________


Policy on Confidentiality and Dissemination of Patient Information and Staff Member Verification Given the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course or our work. Pulse Medical Staffing prohibits the release of any patient information to anyone outside the department or facility except in limited circumstances and discussions or disclosures of protected health information (PHI) within the organization should be limited to the minimum necessary that is needed for the recipient of the information to perform their job. Acceptable uses of PHI within the organization include but are not limited to peer review, internal audits, quality assurance and billing. I understand Pulse Medical Staffing provides services to area healthcare facilities patients that are private and confidential and that I am a crucial step in respecting the privacy rights of these patients. I understand that it is necessary, in the rendering of Pulse Medical Staffing services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected by federal and state laws that prohibit its unauthorized use or disclosure. I have received training in the confidentiality policies and procedures set in place by Pulse Medical Staffing, listed in my personnel file and agree I will comply with such policies and procedures during my entire employment with Pulse Medical Staffing. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify Pulse Medical Staffing HIPAA Privacy Officer Liaison immediately. In addition, I understand that breach of patient confidentiality or privacy may result in disciplinary action up to and including suspension or termination of my employment with Pulse Medical Staffing. Upon separation of my employment for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. I have read and understand all privacy policies and procedures that have been provided to me by Pulse Medical Staffing. I agree to all conditions of my employment set forth in this agreement. This is not a contract of employment and does not alter the nature of the at-will employment relationship between Pulse Medical Staffing and me. Signature: ________________________________________ Date: ______________________ Printed Name: _____________________________________ Reviewed by: ______________________________________

Documents

Pre-Employment Check List - Pulse Medical Staffing · 620 N. Trade Winds Parkway Suite A Columbia, MO 65202 Toll Free Phone & Fax 877.883.8677 Pre-Employment Check List Please provide