TRIUMPH STAFFING APPLICATION

Triumph Staffing Application

WE ARE AN EQUAL OPPORTUNITY EMPLOYER
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, disability, marital status, or any other legally protected status.

Please Fill all Fields, Then When You Finish, Click Submit.
Position Applied For *
Location *
Which Location Are You Applying For?
Name

First Name Middle Name Last Name
Gender
Date of Application

Month Day Year
Date
Address
Address Line #2
City
State
Zip Code
Email Address
Cell
When Is The Best Time To Contact You?

8am-10am 10am-12pm 12pm-2pm 2pm-4pm 4pm-6pm
Can You Travel If The Job Requires It?
Yes/No
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Personal Assessment

Rate Yourself as Your Former Employer Would, 1 Star Being: Struggling - 5 Star Being: Excellent
Rate Your Reliability
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Referral
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Are you prevented from lawfully becoming employed in this country because of visa or immigration status (Proof of citizenship or immigration status will be required upon employment)
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Employment Experience
Are You Currently Employed?
Yes/No
Previous / Or Current Employer
Work Performed
May We Contact Your Employer?

Yes No
Applicants Statement: I certify that answers given herein are true and complete I have given a comprehensive record of my work history for the last 5 years, and/or I have explained all breaks in employment history I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment beyond this time period shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time I hereby understand and acknowledge that, unless otherwise definedlaw,with this byapplicableemploymentrelationshiporganizationis any resignat any time and the employer may discharge employee at anytime with or without cause. It is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment I understand that false or misleading information given in my application or interviews(s) may result in discharge. I understand also, that I Am required to abide by all rules and regulations of the employer.
DATE OF SIGNATURE

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Date
Applicants Signature *

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Please List Your Professional Reference
Professional Reference Verification Form I authorize the release of the following information regarding my personal character:
Name
Relationship
Contact Number
Applicant Signature

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TRIUMPH STAFFING CRIMINAL BACKGROUND VERIFICATION
DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR EMPLOYMENT PURPOSES

Triumph Staffing, LLC may request from a consumer reporting agency and for employment-related purposes, a Background Report containing background information about you in connection with your employment.

HireRight, LLC will prepare or assemble the background reports for Triumph Staffing,LLC

The Background Report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include: Criminal History Litigation History; Motor vehicle records, Social Security Number Verification, Address, Credit History, Verification of Education, Employment and Earning History, Professional Licensing, Credential and Certification Checks; Drug/Alcohol Testing Results and History;Military Service;and other information

I authorize TRIUMPH STAFFING AGENCY permission to perform a complete CRIMINAL BACKGROUND CHECK & DMV (DEPARTMENT OF MORTOR VEHICLE) ran on file in the HUMAN RESOURCE DEPARTMENT and all other reports described above about me as of this application's date.
Do You Agree With The Terms Listed Above? *
Yes/No
Applicants Full Name
DATE OF SIGNATURE

Month Day Year
Signature *

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Are You Currently Vaccinated With Both Doses For COVID-19 *
Yes/No
How did you learn about us? (Advertisement, Website, Friend, etc.)

Nurse Skills Checklist

FOR LPN / RN ONLY
In order to provide suitable assignments for you, the following checklist is a method of assessing your professional profiency as a Nurse. Please rate your skill level as accurately as possible by placing a Rating 1-5 in each approiate field.

1 = No Experience; Theory/Observed Only

2 = Intermittent Experience

3 = Moderate Experience >5 Times Per Year/Needs Review

4 = Competent; Performs On A Daily or Weekly Basis/Proficient

150 Skills
Skill Level
Name
Date

Month Day Year
Medication Administration
Documentation on M.A.R

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Dose Calculation

1

2

3

4

5

1 is Inexperiened , 5 is Competent
Generic Equivalents

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Usage of PDR

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Knowledge of Drug Actions/Interactions

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Verification of Narcotic Wastage

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Oral Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Sublingual Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Intradermal Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Parenteral Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Subcutaneous Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Intramuscular Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Tropical Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Eye Drops

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Ear Drops

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Swallowing Precations

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Inventory and Storage Control

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Infectious Control
AIDS/HIV Interaction

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Hepatitis Interaction

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Hospice

1

2

3

4

5

1 is Inexperienced , 5 is Competent
MRSA

1

2

3

4

5

1 is Inexperienced , 5 is Competent
VRE

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Fever Managment

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Interpretation Of Labs

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Decubitus/Wound Care (Contaminated)

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Linen-Transporting, Storing, & Handeling

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Cleaned

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Soiled

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Personal Clothing

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Proper Disposal of Sharpes And Waste

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Standard Precautions

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Pain Management
Documentation and Assessments of Site, Character, & Frequency of Pain

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Pain Levels

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Documentation of Response to Pain Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Intravenous Therapy

If I.V Certified Then (Check "4")
Administration of I.V Antibiotics

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Administration of I.V Fluids

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Administration of I.V Pain Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Administration of I.V Cardiac Meds

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Blood Draws - Peripheral

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Blood Draws - Central Line

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Blood Draws - Implanted Catheter

1

2

3

4

5

1 is Inexperienced , 5 is Competent
I.V Dose Calculations

1

2

3

4

5

1 is Inexperienced , 5 is Competent
I.V Insertion - Peripheral

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of Infusion Pumps

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Diabetic Care
Diabetic Monitoring

1

2

3

4

5

1 is Inexperienced , 5 is Competent
S/S Hyper/Hypoglycemia

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Diabetic Patient Teaching

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Performing Fingersticks

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of Glucometers

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Insulin Infusions

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Regular, Long-Acting Insulin

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Mixed Insulin

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Psychosocial Problems
Assessment and Documentation of Behavioral Problems (Target Behaviors)

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment and Documentation of S/S of Depression

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment and Documentation of Patient Response to Psychotropic Medication

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Parameters for use of Restraints in Long-Term Care Settings

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment and Documentation of Effectiveness of Preventive Medicine Medications

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Orthopedics
Assessment of Circulation

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Gait

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Range of Motion

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Amputation Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post-Arthroscopy Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Casts and Related Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Osteoporosis

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Pinned Fractures

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Total Hip Replacement

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Total Knee Replacement

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Rheumatic/Arthritic Disease

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Continuous Passive Motion

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Canes

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Cervical Collar

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Gait Belts

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Prostheses

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Slings

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Transfer Board

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Walker

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Wheelchair

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Cardiovascular Problems
Auscultation of Rate/Rythym

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Blood Pressure

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Doppler

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Pulses

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Circulation Checks

1

2

3

4

5

1 is Inexperienced , 5 is Competent
CPR

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post-Abdominal Aortic Bypass

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Angina

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post Carotic Endarterectomy

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Fem-Pop Bypass

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Permanent Pacemaker

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post Acute M.I

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post Cardiac Surgery

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Thrombophelbitis

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Congestive Heart Failure

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Administration of Post-Op Cardiac Meds

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Gastrointestinal Problems
Administration of Tube Feedings

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Administration of Medications via Tube

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Inflammatory Bowel Disease

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Bowel Prep

1

2

3

4

5

1 is Inexperienced , 5 is Competent
G.I Bleeding

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Gualac

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Nutritional Status

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Colostomy Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post Abdominal Surgery

1

2

3

4

5

1 is Inexperienced , 5 is Competent
NG Tube Placement And Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Nasoinstestinal Tube Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Bowel Tones

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Abdomen

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Ebena Administration

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Bowel Incontinence

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Signs and Symptoms of Fecal Impaction

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Neurological Problems
Post-Op Anticonvulsant Medication

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessing Levels of Consciousness

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Dementias (Re-Direction/Validation)

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Neuromuscular Disease

1

2

3

4

5

1 is Inexperienced , 5 is Competent
CVA

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Pupil Check

1

2

3

4

5

1 is Inexperienced , 5 is Competent
A.I.M.S

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Seizure Precautions

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Administration of Anticonvulsant

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Spinal Cord Injuries- Long Term

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Urinary Problems
Assessment and Care of AV Shunt

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Post Renal Surgery

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Renal Failure

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of Urinary Incontinence

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment of I & O Data

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of Bladder Scanner

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Signs and Symptoms of UTI

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Indwelling Catheter

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Indwelling Catheter Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Straight Catheter Insertion

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Suprapubic Catheter Care

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Screening for UTI via Urine Dipstick

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Wounds, Pressure Sores, and Skin Impairments
Assessment and Care of Post-Surgical Wounds

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment, Prevention, and Care of Pressure Ulcers

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Assessment and Documentation of Skin Conditions/Wounds

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Dressing Changes - Asceptic

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Dressing Changes - Sterile

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Wound Irrigation

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Application of Wound Care Products

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of Air Fluidized, Low Air-Loss Beds

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of Pressure-Relieving Seat Cushions

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Staple and Suture Removal

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Other Skills
Alert Charting System

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of 24-hour Written and Verbal Reporting Systems

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Use of "911" in LTC Setting

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Regulatory Guidelines Related to the Prevention of Abuse and Neglect of Residents

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Regulatory Guidelines Related to Resident Rights in LTC Setting

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Discerning Code Status

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Incident and Accident Reporting

1

2

3

4

5

1 is Inexperienced , 5 is Competent
Date Of Signature

Month Day Year
Signature

Clear
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