Request and Intake Form

Facility Information

Facility/Organization NameFacility Type (Hospital, SNF, RCFE, Clinic, Other)Location AddressFirst NameLast NameTitlePhone NumberEmail

Staffing Needs & Timeline

Positions Needed (check all that apply)

Nursing

Registered Nurse (RN) Licensed Vocational Nurse (LVN) / Licensed Practical Nurse (LPN) Certified Nursing Assistant (CNA) Nurse Aide / Caregiver

Allied Health Professionals

Respiratory Therapist (RT) Physical Therapist (PT) Physical Therapist Assistant (PTA) Occupational Therapist (OT) Certified Occupational Therapy Assistant (COTA) Speech-Language Pathologist (SLP) Recreational Therapist

Technologists & Technicians

Radiology / X-Ray Tech MRI Tech CT Tech Ultrasound / Sonography Tech Laboratory Tech / Medical Lab Technician (MLT) Pharmacy Tech Surgical Tech / Scrub Tech Dialysis Tech EEG / EKG Tech

Medical & Clinical Support

Medical Assistant (MA) Behavioral Health Technician / Mental Health Worker Case Manager / Care Coordinator Administrative / Medical Office Staff Unit Clerk / Ward Clerk

Specialty Support

Home Health Aide (HHA) Dietary Aide / Nutrition Assistant Activities Coordinator (RCFE/SNF)

Other (please specify)Anticipated start date(s)

Assignment type:

Ongoing Short-term Specific dates

Shift type(s) needed

Day Evening NOC/Overnight 12-hour 8-hour

Average patient/resident load or staff-to-patient ratioHow far in advance will you typically request staff?SelectIn advanceDay ofTimekeeping systemSelectElectronicPaper timesheets

Minimum experience required

New grad 6 months 1 year 2+ years

Population-specific experience required? (geriatrics, pediatrics, memory care, critical care, etc.):Orientation/training required before starting?SelectYesNo

What credentials must staff provide before assignment?

License CPR/BLS ACLS PALS TB test Physical exam Flu/COVID vaccination Other

Background check required?

Yes No

Live Scan fingerprinting required?

Yes No

Do you conduct your own Live Scan fingerprinting?

Yes No

Drug screening required?

Yes No

Any facility-specific onboarding or policy acknowledgement required?

Yes No

Budgeted bill rate or pay range for each role if availableContract terms required (minimum hours, cancellation notice, buyout options)Expected payment timeline:

Have you worked with staffing agencies before?

Yes No

If so, what worked well and what would you improve?Anything else we should know to ensure the right match?

Website

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