Emergency Staffing Request Needs Assessment
Thank you for taking time to complete this assessment. Your responses will help us create a customized staffing solution for facility.
FACILITY INFORMATION
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Main Hospital
Secondary Hospital
Outpatient Center
Other
Department/Unit
Floor/Location
Request Contact
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First Name
Last Name
Position
*
Contact Email
*
example@example.com
Direct Phone
*
Please enter a valid phone number.
STAFFING DETAILS
Position Requested
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RN Critical Care
RN Emergency
RN Med-Surg
Respiratory Therapist
CNA
ICU Specialist
Telemetry Nurse
OR/Surgical Tech
LPN
Pharm Tech
Medical Lab Tech
Behavioral Health
Other
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Specialty Requirements
Certification Requirements
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ACLS
BLS
PALS
NIH Stroke
Other
# of Staff Needed
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Shift Length
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4 hrs
8 hrs
12 hrs
Other
Shift Time
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Days (7a-7p)
Nights (7p-7a)
Otther
URGENCY LEVEL
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STAT (Within 2 hours)
Today
Within 24 hours
Within 48 hours
Other
ASSIGNMENT DURATION
Type of Coverage
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Single Shift
Multiple Days
Ongoing
Start date
End date
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Indefinite date
Specific date
*
Possibility of Extension
Yes
No
Unknown
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