Healthcare Medical Staffing Form

HEALTHCARE MEDICAL STAFFING FORM

Assignment and Agency Information

Personnel / Contact Information

Date of Birth:   Gender:

Emergency Contact

Licensure, Certifications & Insurance

Primary Professional License Type:  Number:  Issuing State:  Expiration:

Immunizations & Health Screening

TB Test / Screen Date:  Result: Negative Positive

COVID-19 Vaccination: Vaccinated  Doses and dates:  Booster: Yes

Hepatitis B / MMR / Varicella status (provide dates or N/A):

Work Preferences & Availability

Shift Availability: Day Evening Night   Earliest Available Start Date:

Employment History & Professional References

Background Checks, Drug Screening & Authorizations

By signing below, I authorize the staffing agency, its agents and contracted facilities to verify all information provided, to obtain criminal background checks, DMV and credential verification, and to order drug and alcohol testing where required by assignment. I understand that positive results, material misstatements or omission of required information may disqualify me from assignments and may be grounds for termination of assignments or contracts.

Consent (check all that apply):
Background check Drug/alcohol screening Credential verification Professional reference check

Confidentiality, HIPAA & Professional Conduct

I acknowledge that as a staffed healthcare professional I will have access to confidential patient information. I understand my legal and contractual obligations under privacy and confidentiality laws and agree to access, use and disclose patient information only as permitted for the performance of assigned duties. I further acknowledge that violation of confidentiality, unauthorized access, theft, negligence or other conduct jeopardizing patient safety or facility operations are grounds for immediate removal from assignment and potential disciplinary action.

Acknowledgment: I acknowledge and agree to comply with confidentiality and HIPAA obligations.

Applicant Certification

I certify that all information provided on this form and in any supporting documentation is true, complete and correct to the best of my knowledge. I understand that falsification, omission, or concealment of material facts may result in denial of assignment, termination and potential legal action. I agree to promptly notify the staffing agency of any change in licensure status, certification, health status that affects my ability to perform duties, and any criminal charges or convictions occurring after the date of this form.

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