Infusion Nurse Application

Infusion Nurse Application
Effective March 2024
This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant's/employee's ability to perform the essential functions of the position.
Date Available to Start Work*

MonthDayYear
Date
Personal Information
Name*
Last | First | Middle
Current Physical Address*
Street | City | State | Zip
Mailing Address (if different than present address)
Street | City | State | Zip
List any other name(s) you have previously worked under, such as maiden name
Telephone #*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Emergency Contact Person*
Name | Address | Phone Number
1. Nursing Experience
A. Do you have a valid Nursing License for your state or a Compact Nursing License?*

YesNo
B. How long have you been a Registered Nurse?
Years:blanks* Months: blank*
C. Of that, how long have you been in Home Infusion?
Years:blanks* Months: blank*
D. Have you ever given specialty medications (i.e. IVIG) biologics, or antibiotics in the home?*

YesNo
E. Can you access ports?*

YesNo
F. Do you do PICC dressing changes?*

YesNo
G. Which specialty infusion companies are you familiar with?
H. Describe your IV skills?*
2. Employment Desired
A. Salary required
B. Hours available to work:*

DaysEveningsNightsWeekends
C. Will accept employment of:*

Part-TimeFull TimeOccasional part time
D. Will accept employment of:*

Contractor (1099)SalariedOther
3. Prior Work History
List your last four (4) jobs beginning with your most recent or current employer.
Employer's Name*
Telephone Number*
Format: (000) 000-0000.
Employer's Address*
Position Held*
Supervisor*
Dates Employed: START (month/year)

MonthDayYear
Date
Dates Employed: END (month/year)*

MonthDayYear
Date
Salary
Reason for Leaving*
Employer's Name*
Telephone Number*
Format: (000) 000-0000.
Employer's Address*
Street | City | State | Zip
Position Held*
Supervisor*
Dates Employed: From (month/year)*

MonthDayYear
Date
To (month/year)*
Salary
Reason for Leaving*
Employer's Name*
Telephone Number*
Format: (000) 000-0000.
Employer's Address*
Supervisor*
Dates Employed: From (month/year)*

MonthDayYear
Date
End Date: (MM/YYYY*
Salary
Reason for Leaving*
Employer's Name*
Telephone Number*
Format: (000) 000-0000.
Employer's Address*
Street | City | State | Zip
Position Held*
Supervisor*
Dates Employed: From (month/year)*

MonthDayYear
Date
To (month/year)*
Salary
Reason for Leaving*
List name(s) of all other employers for the last five (5) years:*
May we contact your present employer?*

YesNoNot applicable
Have you ever been terminated or asked to resign from any position?*

YesNo
If yes, provide reason.
4. Educational Background

List all educational schools attended with degrees, diplomas or certificates received.*

Rows	Name of Institution (High School, Technical School, College)	Type of Studies	Dates Attended & Diplomas, etc.

If your school or employment records are under another name(s), indicate that name(s)
References List: Name, email address and telephone number of three (3) references who are not relatives or former employers.*
5. Background Information
If you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to:

1. State and/or jurisdiction.

2. Nature of complaint/offense.

3. Disposition of complaint and/or offense (e.g., “dismissed insufficient evidence”, “deferred sentence”

4. Date of disposition.

5. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.
A. Yes/ No: Have you ever 1) Participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pled guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?*

YesNo
If yes, explain:
B. Yes/ No: Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the practice of a health care profession?*

YesNo
If yes, explain:
C. Yes/ No: Are any disciplinary actions or allegations, pending or substantiated against you or your certification or health care professional license in any state or U.S. jurisdiction?*

YesNo
If yes, explain:
D. Yes/ No: Have you had any certificate license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority?*

YesNo
If yes, explain:
File Upload

Cancelof
6. Applicant’s Certification and Agreement
Please Read Carefully - If you answer "No" to any of the questions below, explain in the space after the question.
A. Yes/No: I understand the employer has the right to proceed with any criminal background check.*

YesNo
If no, explain:
B. Yes/No: I understand as part of the job selection process, I may be required to take a drug-screening test at the time of employment and if requested in accordance with the state and federal law at anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. if I refuse to sign this form and submit to drug testing the employer will reject my application.*

YesNo
If no, explain:
C. Yes/No: I understand if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986.*

YesNo
If no, Explain:
D. Yes/No: I understand this form is not an employment contract.*

YesNo
If no, Explain:
***NOTICE***

I UNDERSTAND PROVIDING FALSE OR MISLEADING INFORMATION IS GROUNDS FOR DENIAL, SUSPENSION, WITHDRAWAL, AND/OR NONRENEWAL OF EMPLOYMENT. I ALSO UNDERSTAND PROVIDING FALSE INFORMATION OR OMISSION OF FACTS MAY DISQUALIFY ME FROM EMPLOYMENT AND MAY CAUSE TERMINATION IF DISCOVERED AT A LATER DATE.
I certify I have read and completed this application and that the information I have provided on this application is true and complete.*

YesNo
Signature of Applicant*
Signature Date*

MonthDayYear
Date
Should be Empty:

Infusion Nurse Application

Effective March 2024

Personal Information

1. Nursing Experience

2. Employment Desired

3. Prior Work History

List your last four (4) jobs beginning with your most recent or current employer.

4. Educational Background

5. Background Information

6. Applicant’s Certification and Agreement