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Intake Form
Hospital and Facility Intake Form
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Name of Facility/Hospital
(required)
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Your Unit or Floor
(required)
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Unit/Floor Direct Phone Number
(required)
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Address
(required)
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Manager’s Full Name
(required)
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Manager’s Email
(required)
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Manager’s Direct Phone Number
(required)
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Other contacts number and email.
(required)
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What is your pay scale for contract Registered Nurse?
(required)
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What kind of nurse do you need?
(required)
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Type of hospital and how many beds?
(required)
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Does the nurse need to float?
(required)
Select one option
Yes
No
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Type of Facility and Staff ratio:
(required)
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What certifications do you need the nurse to have?
(required)
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What are the duties?
(required)
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What dates do you need covered?
(required)
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What kind of shifts do you need?
Select one option
8 hour shift
12 hour shift
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Housing must be provided and be as private as possible. Everything should be present to cover the basic needs. If you have housing available please describe it.
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Please provide any other information we may need.
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