SECTION I:
LBH LABOR POOL
Date / Time:
ENTITY:
*
EMPLOYEE ID#: (PLEASE INPUT EMPLOYEE ID#)
DEPARTMENT:
*
EMPLOYEE NAME:
*
JOB TITLE:
*
FTE:
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
1
WORK STATUS:
LEADER / SUPERVISOR:
*
LEADER / SUPERVISOR EMAIL:
*
example@lifebridgehealth.org
EMPLOYEE PHONE #:
AVAILABLE FOR LABOR POOL (Y/N):
*
YES
NO
CLINICAL / NON-CLINICAL:
*
CLINICAL
NON-CLINICAL
SCHEDULED SHIFT:
DAY
EVENING
NIGHT
SKILL SET:
(i.e. EPIC or CERNER access, Med/Surge experience, etc.)
WORKING (ON-SITE / REMOTE):
ON-SITE
REMOTE
OTHER
FURLOUGHED (PARTIAL / COMPLETE):
*
PARTIAL
COMPLETE
OTHER
START DATE:
*
/
Month
/
Day
Year
END DATE:
/
Month
/
Day
Year
NOTE:
(other pertinent details, including reasons for indicating 'no' for availability for labor pool)
Submit
SECTION COLLAPSE REDEPLOYMENT INFORMATION:
REDEPLOYMENT INFORMATION
To Be Completed by HR
REDEPLOYMENT ASSIGNMENT (ENTITY/DEPARTMENT):
REDEPLOYMENT DATE:
/
Month
/
Day
Year
Date
REDEPLOYMENT END DATE:
/
Month
/
Day
Year
Date
RETURN TO WORK DATE:
/
Month
/
Day
Year
Date
REFUSED LABOR POOL ASSIGNMENT (Y/N)
YES
NO
COMMENT:
Submit
Should be Empty: