Name:

Title:   

Facility Name:

Address:

City:   State: -- AK AL AR AZ CA CO CT D.C. DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY   Zip:

Phone:   Fax:

Email:

Approximate Date Needed:
          -or-
Select closest time: ----- Immediately / ASAP! Within next 30 days Within next 3 months Within next 6 months Within next 9 months Within next 12 months

Approx. Length of Assignment  (pick closest): 13 Weeks 26 Weeks Per Diem Permanent Placement

Tell us about your facility and your needs ....

Clinical Areas for RCP to work in your facility (select all that apply):

     General Floor       ICU        CCU         NICU        Peds 
     ER/Trauma    Open Hearts  Other

Please list the ventilators used in your facility:
   

Charting Methods Used:
    Written Only    Computerized Only    Combination

     If computerized, please list which:

Do you currently use outsourced supplemental staffing?   Yes    No

I am interested in the following information (check as many as you'd like):

    General Brochure/Information

    Information about IRS's Rates for their various programs

    References

    Customized Proposal for my organization with a Cost/Benefit Analysis

Thank you for your time and interest in Immediate Respiratory Staffer's RCP Staffing Solutions.  Please click on the Submit button below and a representative will contact you shortly.