HR Nursing Questionnaire

HR Nursing Questionnaire

Personal Information

Full legal name:

Phone:    Email:

Date of birth:

Position Information

Reporting manager (if known):    Desired start date:

Professional Licensure and Certifications

License type:    License number:

Issuing state:    Expiration date:

BLS    ACLS    PALS    NRP    Other (specify below)

Clinical Skills and Experience

Years of professional nursing experience:

IV insertion — yrs:    Medication administration — yrs:
Wound care — yrs:    Foley catheterization — yrs:
Telemetry care — yrs:    Neonatal care — yrs:

Employment History (Most Recent First)

Education

Graduation date:

References

Please provide three professional references.

Phone:    Email:

Phone:    Email:

Phone:    Email:

Health, Immunizations and Safety

Immunization documentation provided: MMR    Varicella    Tdap    Hepatitis B series documented

Influenza vaccination for current season: Yes    No

Most recent test date:    Result:

No    Yes — if yes, describe below

Background, Professional Conduct and Claims

No    Yes — explain below

No    Yes — explain below

No    Yes — explain below

Work Availability and Logistics

Are you legally authorized to work in this country? Yes    No

Do you have a valid driver's license if required for position? Yes    No

Day shift    Night shift    Weekends    Per diem / PRN

Legal Disclosures & Authorizations

At-Will Employment: I understand that, if employed, my employment relationship is at-will and may be terminated by either party at any time, with or without cause or notice, unless a separate written agreement signed by an authorized representative states otherwise.

Equal Employment Opportunity: The organization provides equal employment opportunity in all employment practices and does not discriminate on the basis of protected characteristics in accordance with applicable law.

By selecting yes below and signing this form, I authorize the organization to verify all information provided, contact current and prior employers, educational institutions, licensing boards, and references, and to obtain consumer and/or criminal background checks and drug screening as a condition of hire.

I authorize these checks    I do not authorize (explain below)

Drug Screening: I understand that a negative drug screen may be a condition of employment and that a positive result may disqualify me from consideration or be grounds for termination if employed.

I consent to drug screening    I do not consent (explain below)

Applicant Certification

I certify that all information provided in this Nursing Questionnaire is true, complete and correct to the best of my knowledge. I understand that omission, misrepresentation, or falsification of information may result in refusal of employment or termination of employment if discovered at a later date. I acknowledge that I have read and understand the statements above regarding background checks, drug screening and at-will employment.

I authorize any person or institution to release information requested by the organization to verify the accuracy of statements made in this questionnaire. I hereby release all such persons and institutions from liability for furnishing such information.

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