Nursing Professional Profile
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General Information
Name
*
First
Middle
Last
Profession: Please check all that apply
*
RN
LPN
CNA
HHA
Number of years?
Instructions:
Complete applicable items only
EXPERIENCE:
Please check all areas in which you have experience
ER
ME/SURG
RR
ICU/CCU
STEP DOWN
TCU
REHAB
HOME HEALTH
L & D
POST PARTUM
NURSERY
PEDIATRICS
OR
CATH LAB
MONITOR TECH
PSYCH
PROFESSIONAL LICENSURE:
License No:
State Issued:
License No:
State Issued:
License No:
State Issued:
Certifications:
Select all that apply:
BLS/CPR
PALS
OTHER
OTHER
ACLS
TNCC
OTHER
OTHER
NAS
CCRN
OTHER
OTHER
SPECIALIZED TRAINING:
Have you had a formal critical care course?
Yes
No
Date Completed:
Have you had an arrhythmia course?
Yes
No
Date Completed:
Are you I.V. certified?
Yes
No
Date Completed:
Are you chemotherapy certified?
Yes
No
Date Completed:
PROFESSIONAL LIABILITY:
Do you carry professional liability insurance?
Yes
No
UNIT OR FLOOR PREFERENCE:
Please select one:
*
First Floor
Second Floor
Third Floor
CHICKEN POX STATEMENT:
Yes, I have had chicken pox
No, I have not had chicken pox
Signature
Date
