PERSONAL INFORMATION 

First Name                                   Middle Name                               Last Name   

Alternate Last Name(s), if applicable,  in which degrees, licenses, credentials, etc. would be listed

 Social Security #        Date Available            E-mail Address                    Work Visa # (if applicable)
          

 Current Address

 City                                                                                  ST               Zip
     

The address above is _____.  Permanent    Temporary
 Day Phone                        Eve Phone                        Cell Phone                        Pager
     

The best time to reach you is -- 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 A.M. P.M. . 
By which number(s) should we attempt to contact you? Day Eve Cell Pager

  Please Select Way In Which You Found Out About IRS             Please List Name of Source
----- School (via faculty recommendation or flyer) Medical Facility (via superior or flyer) Newspaper Ad Respiratory Trade Magazine (i.e. Advance) National or State Respiratory Board National or State Respiratory Association Link from another Web Site Friend or Colleague  

I am interested in the following:

Per Diem Work (day by day assignment in a specific area)    
Travel or Local Assignment (i.e. committment for 6/13/26 weeks/ time)
Permanent Placement (on staff w/ one facility in my area or new area)

Please list locations in which you have interest in working

Do you have reliable transportation for daily work commute?  Yes  No
Will you be bringing a vehicle to a travel assignment?              Yes  No

Work Preferences (select as many as you wish)
Days  Eves  Nocs  4-hr  8-hr  12-hr  16 (doubles okay)

Most facilities prefer to provide a shared housing environment for travelers, with a one or two roommate situation. If travel is one of your interests, are you amenable to a roommate situation?  Yes  No  Will not need subsidized housing (provide own)

LICENSURE / CREDENTIALS 

Do you/have you held additional licenses other than listed above? Yes  No

Please answer the following with regard to any State license issued to you:
     Has a complaint ever been filed against you/your license?   Yes   No
     Has your license ever been investigated, suspended or revoked?   Yes   No
     Have you ever been named in a malpractice or negligence suit?   Yes   No

     Have you ever been convicted, found or pleaded guilty, or pleaded no
          contest to a felony?   Yes   No

If you answered yes to any of the preceding, please explain the details regarding the item(s).  List the States or Provinces in which they occurred, dates, circumstances, and current status or outcome.  Please be sure to include any information about stipulated orders.  And, please be as detailed as possible.
    

NBRC Credentials:   CRT   RRT  

Please list the expiration dates for any of the following credential you have obtained
ACLS   BCLS   NALS   PALS
Please list the names and expiration dates for any other credentials/non-rcp licenses you hold

CLINICAL SKILLS

In an effort to match your unique strengths with the needs of the requesting medical facility, please rank yourself on the items in this section using the following key.

1 =  Highly Experienced (2-5+ years).  You have a strong amount of experience in this area, are proficient and will feel comfortable working alone or with minimal supervision.

2 =  Experienced (1-2 years).  You have a growing amount of experience in this area and are fairly proficient.  You can take an assignment if you have someone else in the unit, or prefer not to be alone.

3 = Some Experience.  You have been introduced to the skill in school, clinicals, or helping out in the unit, but you don't have the ventilator experience, airway management skills or comfort level to be alone on your own in all required areas. 

Charting Methods Familiar With: Written   Computerized  Both

List computerized charting programs you are experienced with

EDUCATION
(List Name, Address and Phone for each in the appropriate scroll box)

Grade School - Degree Earned? Yes  No

High School - Degree Earned? Yes  No

College - Degree Earned? Yes  No


Respiratory School - Degree Earned? Yes  No


Other - Degree Earned? Yes  No

EMPLOYMENT HISTORY 

List most recent first.  When listing a period of time through which you worked through an agency, list the agency and it's related contact information first.  Then, list all travel assignments in separate rows underneath the main agency listing, making sure to list that agency just before the facility name in the scrolling text box, to ensure we understand you worked at that facility as agency personnel.  If you worked at several facilities as per diem through an agency, no need to list those facilities on a separate line.  But, rather, add them in parentheses in the same box as the agency's information immediately following the agency's supervisor's and areas worked.

Thank you for completing this application and for your interest in becoming part of the phenomenal IRS team!  Please press the 'Submit' button below when you are finished filling this out, or fax this form with complete information to (602) 266-6542.  We will contact you shortly.  Again, thank you.  We look forward to being a part of your career path!