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Name of Institution:
Address:
Contact Name:
Staffing Office:
 Phone:
 Fax:
 Email:
Staffing Office Manager:
 Phone:
 Fax:
 Email:
Names of Staffing Specialists and Their Shift Times:
Specialist

 Shift Time
Units and Their Shift Times:
Notes:
 ICU:
D 
E 
N  		Step Down:
D 
E 
N  		ER:
D 
E 
N  		Med./Surg.:
D 
E 
N 
Oncology:
D 
E 
N  		Mother-baby:
D 
E 
N  		NICU/PICU:
D 
E 
N  		OR/PACU:
D 
E 
N 
Hospital Cancellation Times:
Days:
 Evenings:
 Nights:
Are Late Calls Paid? Yes No Minimum Scheduled Hours: 2. 4. 6. 8.
Special Requirements:
Staffing Procedure:
Staffing Office Yes No Nursing Administrator Yes No
Staffing Office Location
Parking Location
Fee?  Yes  No
Cost  Validation  Close 
Dress Code
Whites    Street Clothes    Scrub top & Bottom
Lab Coat    Scub Top    Other
Who supplies the uniform?
OrientationYes No Length of orientation   
Who provides it? At what rate is it paid?
Faxed Yes No Review location Facility Office
Online Yes No
Credentials required on person?Yes No Present at facility Fax in advance
Which are required?
License CPR ACLS/PALS/NRP
Fire Card Other
Facility Floors
 Units
 Ages/Types of patients
 Number of beds
Classifications of staff needed
RN LPN LVN RRT
CRRT CNA MA HHA
ORT ST RT Other
Areas Utilized
Units Floors Pharmacy Radiology
Clinic HHA Psychiatric Lab
OR Other
Directions
North
 South
 East
 West

 

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