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STEEEP ADVANTAGE

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Personal Information
Professional Credentials
Employment History
Legal Questions
Professional Letter of Reference
Education
Annual Mandatory Education
Professional Letter Refrence
Regester Nurse
Iv Certification
Confidentiality Statement
Conflict of Interest
Authorization
Annual TB Question
hepatitis B Vaccine
Hepa Fit Test
Form W 4
Employment Eligibility
Employee Direct Deposite
Non Employee
Private Physician

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Personal Information

Name

Date Available Employment Desired :

Travel

Local Contract

Per Diem (minimum 2 shift/week)

Nick Name

Social Security #

Current Mailing Address

Current Phone

Cell Phone

Best Time to Contact

Permanent Mailing Address

Are You a U.S Citizen?

Yes

Emergency Contact Name

Relationship

Phone

Were you referred by anyone? If so, who?

Speciality(List most current experience first)

1 Years of Experience

2 Years of Experience

3Years of Experience

As of (indicate date)

PLEASE INDICATE WHICH OF THE FOLLOWING CREDENTIALS YOU CURRENTLY HOLD

BLS

ACLS

PALS

NRP

CHEMO

CEN

CCRN

TNCC

OCN

Critical Care Course

First Assist

Current Licenses and Certification

Licence Type

Issue Date

License Number

Expiration Date

State

Licence Type

Issue Date

License Number

Expiration Date

State

Licence Type

Issue Date

License Number

Expiration Date

State

Faculty

Position Held

Dates Employed

Supervisor Name & Title

Teaching Facility

Yes

Avg. Patients ratio

Charge Experience?

Yes

City

Specialty/Unit/Dept

Reason for leaving

Phone

# Hospital Beds

Was this a Travel/Per Diem Assignment?

Yes

How often?

State

Salary

Unit Size/# Beds

If yes, what company?

May we contact employer?

Yes

Faculty

Position Held

Dates Employed

Supervisor Name & Title

Teaching Facility

Yes

Avg. Patients ratio

Charge Experience?

Yes

City

Specialty/Unit/Dept

Reason for leaving

Phone

# Hospital Beds

Was this a Travel/Per Diem Assignment?

Yes

How often?

State

Salary

Unit Size/# Beds

If yes, what company?

May we contact employer?

Yes

Are you aware of any cirecumstances, which may result in a malpractice claim or suit being made or brought against you?

Yes

If yes, please indicate dates, circumstances and attache a separate sheet with full particulars.

Date

Circumstances

Outcome

Has any medical claim or suit been brought or theatened against you or your employer for your acts?

Yes

If yes, please indicate dates, circumstances and attache a separate sheet with full particulars.

Date

Circumstances

Outcome

Have you ever been the subject of a reprimand or diseiplinary action or refused employment or admission to a professional society or had professional privileges suspemded by any court or administrative agency, regulatory board or State licencing Board, or ever been the subject of any ethics investigation at local, state, or national level (whether discilined or cleared)?

Yes

If yes, please indicate dates, circumstances and attache a separate sheet with full particulars.

Date

Circumstances

Outcome

At any time, have you ever been charged with a crime or been convicted or pled guilty or no contest to any criminal charge (whether disciplined or cleared)?

Yes

If yes, please indicate dates, circumstances and attache a separate sheet with full particulars.

Date

Circumstances

Outcome

The statement made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment or termination of services. I authorize SAS, Inc. to verify the information I have provided and to contact past employers and references concerning my ability, character and employment records. I release all such persons from liability for furnishing said information. I authorize SAS, Inc. and my employer, to release a copy of this employment application and any credentials and medical information which may be relevant to my employment to their client facilities. By applying to SAS, Inc., I authorize release of this information to all other affiliates of the company and I acknowledge and agree that they may contact me using text, facsimile and any other means. Nothing contained in the employment application or in the granting of an interview, is intended to create an employment contract between SAS, Inc., and applicant for either employment or providing of any benefit. All offers of employment are made conditional upon the applicant's proving employment authorization and identity in accordance with the Immigration Reform and Control Act of 1985.

(Exceptions due to state employment law: Applicants in the following state are not required to answer the above criminal history questions; CA, CO , CT, DC, HI, IL, MA, MD, MN, NE, NY, NJ, NM, RI). For additional U.S Counties and Cities that have employment laws prohibiting the requirements of the above questions, please see the following page.

Signature

Date

Add a border to a table:

FLORIDA	GEORGIA	INDIANA	KENTUCKY
Jacksonville	Atlanta	Indianapolis	Louisville
Tampa
LOUISIANA	MICHIGAN	MISSOURI	NEW YORK
New Orleans	Ann Arbor	Kansas City	Buffalo
	Detroit		New York City
	East Lansing		Rochester
	Genesee Country
	Kalamazoo
	Muskegon County
NORTH CAROLINA	OHIO	OREGON	PENNSYLVANIA
Carraboro	Canton	Multnomah County	Philadelphia
Charlotte	Canton Cincinnati		Pittsburgh
Cumberland County	Cleveland
Durham City	Massillon
Durhma County
Spring Lake
TENNESEE	TEXAS	VIRGINIA	WASHINGTON
Memphis	Austin	Alexandria	Seattle
	Travis County	Newport News
		Norfolk
		Petersburg
		Portsmouth
		Richmond
WINSCONSIN	DISTRICT OF COLOMBIA
Dane County	Washington DC
Milwaukee County

Employment laws in the following U.S countries and cities prohibit employers from requiring applicants to answer questions regarding criminal history at time of application;

You may give this form directly to your supervisor or return to Remede Consulting Group. Inc.

Facility Name

City

Zip

Telephone

Direct Supervisor's Name

Street Address

State

Fax Number

Title

Applicant Information

Applicant Name

Posifica(s) held in your employ

ORT

LPN

Travel Assignment?

Yes

SLP

PTA

COTA

RRT

RERT

CRIT

Rad Tech

Vocational/Nursing School

Degree/Diploma received

Location

Date Graduated

College/University

Degree/Diploma received

Location

Date Graduated

College/University

Degree/Diploma received

Location

Date Graduated

*Name

List your most recent employer first. Please complete all information. If any of the employers listed below are staffing agencies or travel companies, please provide the name of the agency as well as the name of the hospital where you were on assignment. (List each hospital you worked at separately and include the agency name as well).

Faculty

Position Held

Dates Employed

Supervisor Name & Title

Teaching facility

Yes

Avg. Patients ratio

Charge Experience?

Yes

City

Specialty/Unit/Dept

Reason for Leaving

Phone

# Hospital Beds

Was this a Travel/Per Diem Assignment?

Yes

How often?

State

Salary

Unit/Size # Beds

If yes, what company?

May we contact employes?

Yes

Faculty

Position Held

Dates Employed

Supervisor Name & Title

Teaching facility

Yes

Avg. Patients ratio

Charge Experience?

Yes

City

Specialty/Unit/Dept

Reason for Leaving

Phone

# Hospital Beds

Was this a Travel/Per Diem Assignment?

Yes

How often?

State

Salary

Unit/Size # Beds

If yes, what company?

May we contact employes?

Yes

Faculty

Position Held

Dates Employed

Supervisor Name & Title

Teaching facility

Yes

Avg. Patients ratio

Charge Experience?

Yes

City

Specialty/Unit/Dept

Reason for Leaving

Phone

# Hospital Beds

Was this a Travel/Per Diem Assignment?

Yes

How often?

State

Salary

Unit/Size # Beds

If yes, what company?

May we contact employes?

Yes

Faculty

Position Held

Dates Employed

Supervisor Name & Title

Teaching facility

Yes

Avg. Patients ratio

Charge Experience?

Yes

City

Specialty/Unit/Dept

Reason for Leaving

Phone

# Hospital Beds

Was this a Travel/Per Diem Assignment?

Yes

How often?

State

Salary

Unit/Size # Beds

If yes, what company?

May we contact employes?

Yes

Signature

Date

Annual Mandatory Education Acknowledgement

I ____________________________________ have reviewed the educational materials for annual compliance with OSHA and The Joint Commission on the following topics;

Confidentiality and Privacy under HIPAA
Abuse and Neglect
Advanced Directives
Age Specific
Body Mechanics
Care Planning
Complaints and Grievances
Compliance
Cultural Diversity
Environment of Care

Ethics
Falls
HIPAA
Infection Control
latex Allergy
Legal Issues in Healthcare
OSHA Healthcare Safety
Pain Management
Patient Rights
Patient Safety
Quality Improvement
Restraints
Risk Management
Sexual Harassment
Substance Abuse Recognition
Workplace violence
National Patient Safety Goals

Life Safety
Hazardous Materials
Waste Management
Medical Equipment Management
Emergency Preparedness
Utility Management
Security Management
Bio-Terrorism
Fire Safety

Employee Name (Printed)

Employee Signature

Date

You may give this form directly to your supervisor or return to Remede Consulting Group, Inc.

Facility Name

Street Address

City

State

Zip

Telephone

Fax Number

Direct Supervisor's Name

Title

Applicant Information

Applicant Name

Posificm(s) held in your employ

ORT

LPN

SLP

PTA

COTA

RRT

PERT

CRIT

Rad Tech

Travel Assignment?

Yes

Clinical Specialty

Employment Dates From

Average Patient Caseload

No. of Beds in Unit

No of Beds in Facility

Teaching

Non-teaching

Charge Experience?

Yes

Supervisory Experience

Yes

Reason for Leaving

Would you rehire?

Yes

Performance Evalution and Professional Attributes

Performance and Attributes

Demonstrates competency in caring for patients

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Provides a sife and thenpattir patient environunment

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Implements a coordinated plan of patient care

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Adheres to facility policies and procedures

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Communicates appropriately with patients and farmilies

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Completes accurate documentation of patient care

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Flexibility and adaptability

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Willingness and ability to float (if applicable)

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Interest and enthusianon

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Ability to communicate with staff

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Attendance and punctuality

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Overall professionalisam

Exceptional

Above Standard

Standard

Almost Standard

Below Standard

Evaluator's Signature

Date

Title

Telephone

This is information was ontained from

Written Reference

Verbal Reference

JOB SUMMARY The Registered Nurse provided patient care on a supplemental basis to our client facilities. With the delivery of safe, quality patient care as the primary goal, the Registered Nurse exercises sound professional judgement and skill in the performance of assigned duties. The Registered Nurse is expected to practice a systematic approach to patient care utilizing the nursing process; assignment of patient status and needs, planning of patient care based on needs, implementation of the plan of care and evaluation of goal achievement.

QUALIFICATIONS: Must be New York Licensed Registered Nurse • Must have BSN or equivalent • Must have valid CPR/BLS, ALS from American Heart Association or Red Cross • Board certification in speciality (if applicable). • Unrestricted license to practice within specific state • Must have 2 years recent experience within speciality • Malpractice Insurance (I M — 6M coverage) • Critical Care Course (Preferred)

DUTIES AND RESPONSIBILITIES The Registered Nurse is expected to practice safe and ethical nursing care within the scope of his/her profession as defined by state Nurses Practice Act, understanding of his/her own limitations, seeking advice and assistance when necessary. Specific duties may include, but are not limited to the following:

Perform routine nursing care
Provides patient and family teaching
Assists physician with patients
Accurately gives and receives report on patient status
Monitors patient per facility protocol and patient needs
Identifies and acts on change in patient status
Institute comfort and safety measures for patient
Provides age specific care to all patients
Provides patient care with a sensitivity to cultural diversity of patient population
Performs nursing procedures in compliance with the facilities policies and procedures
Consistency practices standard precautions
Adheres to hospital policies for handling, labelling, disposal of bio hazardous materials
Adheres to joint Commission professional standards and incorporates the National Patient Safety Goals into current practice

ESSENTIAL FUNCTIONS: Must have working knowledge of the theory, principles, techniques and practice of professional nursing • Must have current knowledge in caring for patients in different development stages through the cycle to include infants through geriatrics.

Must have a command for the English Language and have ability to communicate both verbally and in writing.
Seeks to obtain educational resource and create leaning experience to enhance and maintain current khowledge and skills for continued clinical competence.
Ability to operate medical equipment.
Frequently move to list between 50 —100 pounds, depending on assignment requirements.
Stand for long periods with frequent squatting, twisting, bending, kneeling, and reaching to prepare equipment, managing patient care environment.
Sensory requirements include speech for communication, and vision, smell, touch and hearing for accurate patient assessment.
Manual dexterity and fine motor coordination.
Ability to work in stressful environment.
Consistent attendance is required to assure that the client facilities' needs and patient needs are met.
While on assignment, the Registered Nurse is responsible and accountable to their assigned patients and to the client facility.
The nurse is under supervision of the charge nurse or other assigned personnel and must have the ability to follow directions/instructions from his/her supervisor.

PHYSICAL DEMANDS

The work involves considerable sitting, standing, and walking. Must be able to work under physical and emotionally stressed conditions. WORKING CONDITIONS:

WORKING CONDITIONS The Registered Nurse must understand and accept the possibility of exposure to inside environment conditions, such as noise, infectious/communicable disc-Aces, blood and blood borne diseases, chemicals and/or chemical fumes, infectious waste, fumes or gases, radiation, occasional exposure to laser and dust. There is also the possibility of physical injury/verbal abuse from an out of control patient. Frequent exposures to distressed patients. Families or visitors.

AGE SPECIFICITY

Knowledge of normal growth and development
Knowledge of appropriate assessment techniques specific for the patient's age
Acquires and maintains current knowledge and competency in nursing practice, and has the knowledge and skills necessary to provide care appropriate to the age of the patients served.

Signature below acknowledge that 1 have received a copy of my job description.

*Name

Signature

Date

I __________________________hereby authorize my employers, both past and present, to provide reference information to SAS, Inc., to include position, dates of employment, eligibility for re-hire, performance and attributes while in their employment.

I hereby release all such employers and their representative from all liability related to the release of this information to SAS, Inc. I also authorize SAS, Inc. to disclose this information only to the client facilities for which I have expressed an interest in being assigned.

Employee Name

Employee Signature

Signature of Represantative

Date

I am interested in finding out how Steep Advantage Services, Inc. can help staff my facility. Please send information regarding Steep Advantage Services's comprehensive list of services.

Yes

*Name

Facility

Title

*Phone

*Email

Name

Date

This is to certify that I,____________________________________________________________ am proficient in intravenous Therapy procedure including but not limited to: venepuncture for continuous infusion, venepuncture for intermittent administrative of IV solution/ medication through a Saline Lock, or venepuncture for Saline Lock.

Nurse Signature

Date

Confidentiality Statement Acknowledgement

As an SAS employee, I understand and acknowledge that:

I must hold confidential and private all information pertaining to patients, patient records, client facility policies, and procedures.
All protected patient information shall be kept safeguarded pursuant to the policies and procedures at each facility, respectively, and in accordance the health insurance
Portability and Accountability Act of 1996 (HIPAA), the regulations issued thereunder, and any applicable state law to prevent impermissible disclosure, loss or misuse, and to ensure that only authorized persons have access to such protected information.
I will consult the Facility Privacy Officer in the event I have any question regarding the scope or application of private policies.
Private and confidential information will only be released to an outside party when legally required to do so and to the extent minimally necessary to respond to that request.
Failure to maintain confidentiality and privacy may lead to disciplinary and/or credentialing board.
I understand that any breach of confidentiality may be grounds for immediate termination of employment as well as any appropriate legal actions.

Employee Signature

Date

Printed Name

Conflict of Interest Acknowledgement

Steeep Advantage Services relies on the good faith of its employees in the exercised of their responsibilities to the company. All business Judgments on behalf of the company should be made, exercising independent judgment in SAS's best interest. Steeep Advantage Services fully respects and upholds employees' right to privacy in their personal affairs and financial activities. However, employees must avoid situations in which their personal activities are or may appear to be in conflict with their responsibility to the company.

Generally, a conflict exists when the personal interests or activities {financial or otherwise} of an employee (or their immediate family member) may influence the exercise of his or her independent judgement in the performance of one or more duties to the company. There may be cases where such conflicts are more theoretical than real, but the appearance of a conflict can be as damaging as an actual conflict.

Because it is not possible to list all situations or relationships which might create of interest problems, and because each situation must be evaluated based on its individual facts, employees should promptly disclose to their supervisors or managers any facts or circumstances which might constitute a conflict of interest or give the appearance of such a conflict. Employees are encouraged to obtain assistance of Management to determine if a conflict exists and, if so, how it should be resolved.

When conflicts of interests arise, Steeep Advantage Services discloses this conflict of interest when appropriate to whenever client may be involved or affected.

I acknowledge that as an employee of Steeep Advantage Services, I have no conflict of interest with my responsibilities to the organization.

Employee Handbook Acknowledgement

I acknowledge that I have received a copy of SAS's Employee Handbook. I have and understand SAS's policies and my requirements as SAS employee. I understand that if I have any questions and/or need clarification for items addressed in the handbook, it is my responsibility to contact the SAS office to discuss.

Employee Signature

Date

Printed Name