Healthcare Staffing Application

1
LPN License State
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
LPN License Number
3
LPN License Expiration Date
Date
Month
Day
Year
4
Any restrictions/discipline on LPN license?
Yes
No
5
Explanation if yes
6
Highest Nursing Education
Please Select
Please Select
Diploma
Associate Degree in Nursing (ADN)
Bachelor of Science in Nursing (BSN)
Master of Science in Nursing (MSN)
Doctor of Nursing Practice (DNP)
Other
7
School Name
8
Graduation Date
Date
Month
Day
Year
9
Please provide accurate information for healthcare staffing opportunities with Charisma SPD. Sensitive onboarding or identity documents may be requested later if you advance in the process.
10
Full Name* This field is required.
First Name
Last Name
11
Preferred Name
12
Email* This field is required.
example@example.com
13
Mobile Phone (Primary)* This field is required.
Please enter a valid phone number.
14
Phone (Alternate) (optional)
15
Are you legally authorized to work in the United States?* This field is required.
Yes
No
16
City, State & ZIP Code* This field is required.
Street Address
Apartment / Unit
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Reliable Transportation* This field is required.
Yes
No
18
Do you have Driver’s License?* This field is required.
Yes
No
19
Languages Spoken
English
Spanish
Chinese
French
German
Hindi
Arabic
Russian
Portuguese
Japanese
Other
Other
20
Position Applied For* This field is required.
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Certified Nursing Assistant (CNA)
Sterile Processing Technician
Flexible Endoscope Reprocessor
OR / Instrument Support
Patient Transport
Environmental Services (EVS)
Administrative / Support
Other
21
Please specify the role
22
CNA Certification/License State
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
23
CNA Certification/License Number
24
CNA Expiration Date
Date
Month
Day
Year
25
BLS/CPR or Other Certifications
BLS/CPR
ACLS
PALS
Other
Other
26
Years of CNA/Patient Care Experience
Please Select
Please Select
<1
1–2
3–5
6–10
10+
27
Primary Healthcare Setting
28
Most Recent Unit/Department
29
Patient Population Experience
Adult
Geriatric
Pediatric
Neonatal
Mixed
Other
Other
30
CNA Certification Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
31
Relevant Certification Type
Please Select
Please Select
CER
CRCST
CSPDT
Other
32
Certification Number
33
Certification Expiration Date
Date
Month
Day
Year
34
Years of Endoscope Reprocessing Experience
Please Select
Please Select
<1
1–2
3–5
6–10
10+
35
Endoscope Reprocessing Experience Areas
Manual Cleaning
Leak Testing
High-Level Disinfection
Sterilization
Drying/Storage
36
AER/Reprocessing Equipment Experience
37
Most Recent Endoscopy/SPD Setting
38
Certification Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
39
Years of OR/Instrument Support Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
40
Surgical Specialties Supported* This field is required.
General Surgery
Orthopedics
ENT
Neuro
Cardiovascular
Urology
GYN
Plastics
Robotics
Other
Other
41
Experience Areas* This field is required.
Case Carts
Instrument Sets
Room Support
Loaners
Other
Other
42
Most Recent OR/Perioperative Setting
43
Relevant Certifications
44
Certification Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
45
Years of Patient Transport/Healthcare Support Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
46
Healthcare Setting Experience
47
BLS/CPR if held
48
Experience with Wheelchairs/Stretchers/Bed Transport* This field is required.
Wheelchairs
Stretchers
Bed Transport
49
Patient Safety Protocol Experience
50
Relevant Certification Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
51
Years of Healthcare EVS Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
52
Facility/Department Setting
53
EVS Experience Areas* This field is required.
Routine Cleaning
Discharge/Terminal Cleaning
Isolation-Room Cleaning
Infection-Prevention Procedures
54
Relevant Training/Certifications
55
Credential Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
56
Years of Healthcare Administrative/Support Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
57
Healthcare Setting
58
Areas of Experience* This field is required.
Scheduling
Front Desk
Data Entry
Patient Access
Office Support
Inventory
Coordination
Other
Other
59
Software/EMR Systems Experience
60
Relevant Certifications
61
Credential Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
62
Years of Relevant Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
63
Most Recent Work Setting
64
Relevant Licenses/Certifications
65
Short Summary of Qualifications
66
Credential Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
67
Will you now or in the future require employer sponsorship to work in the United States?* This field is required.
Yes
No
68
RN License Type* This field is required.
Compact
Non-Compact
Pending
69
Primary RN License State* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
70
License Number* This field is required.
71
License Expiration Date* This field is required.
Date
Month
Day
Year
72
Any restrictions/discipline on any license?* This field is required.
Yes
No
73
Comments / Explanation (Restrictions or Discipline) (if applicable)
74
Highest Nursing Degree* This field is required.
Please Select
Please Select
ADN
BSN
MSN
DNP
Other
75
School Name* This field is required.
76
Graduation Date* This field is required.
Date
Month
Day
Year
77
Certifications Held* This field is required.
BLS
ACLS
PALS
NRP
TNCC
ENPC
NIHSS
CPI
Chemo
Moderate Sedation
Other
78
Certification Details (Issuer + Expiration Date)
Issuer (e.g., AHA)
Expiration (MM/YYYY)
BLS
Row 0, Column 0
Row 0, Column 1
ACLS
Row 1, Column 0
Row 1, Column 1
PALS
Row 2, Column 0
Row 2, Column 1
NRP
Row 3, Column 0
Row 3, Column 1
TNCC
Row 4, Column 0
Row 4, Column 1
ENPC
Row 5, Column 0
Row 5, Column 1
NIHSS
Row 6, Column 0
Row 6, Column 1
CPI
Row 7, Column 0
Row 7, Column 1
Chemo
Row 8, Column 0
Row 8, Column 1
Moderate Sedation
Row 9, Column 0
Row 9, Column 1
Other
Row 10, Column 0
Row 10, Column 1
BLS
ACLS
PALS
NRP
TNCC
ENPC
NIHSS
CPI
Chemo
Moderate Sedation
Other
Issuer (e.g., AHA)
Row 0, Column 0
Expiration (MM/YYYY)
Row 0, Column 1
Issuer (e.g., AHA)
Row 1, Column 0
Expiration (MM/YYYY)
Row 1, Column 1
Issuer (e.g., AHA)
Row 2, Column 0
Expiration (MM/YYYY)
Row 2, Column 1
Issuer (e.g., AHA)
Row 3, Column 0
Expiration (MM/YYYY)
Row 3, Column 1
Issuer (e.g., AHA)
Row 4, Column 0
Expiration (MM/YYYY)
Row 4, Column 1
Issuer (e.g., AHA)
Row 5, Column 0
Expiration (MM/YYYY)
Row 5, Column 1
Issuer (e.g., AHA)
Row 6, Column 0
Expiration (MM/YYYY)
Row 6, Column 1
Issuer (e.g., AHA)
Row 7, Column 0
Expiration (MM/YYYY)
Row 7, Column 1
Issuer (e.g., AHA)
Row 8, Column 0
Expiration (MM/YYYY)
Row 8, Column 1
Issuer (e.g., AHA)
Row 9, Column 0
Expiration (MM/YYYY)
Row 9, Column 1
Issuer (e.g., AHA)
Row 10, Column 0
Expiration (MM/YYYY)
Row 10, Column 1
1 of 11
79
Other Certification Name* This field is required.
80
Other Certification Expiration* This field is required.
Date
Month
Day
Year
81
Total RN Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
82
Do you want to upload documents now?
Yes
No
83
Resume / CV
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
84
RN License Upload
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
85
Certifications Upload (BLS/ACLS/etc.)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
86
Additional documents (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
87
Primary Specialty* This field is required.
Please Select
Please Select
Med-Surg
Tele
ICU
ED
OR
PACU
L&D
NICU
Peds
Psych
LTC/SNF
Home Health
Dialysis
Clinic
Other
88
Years in Primary Specialty* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
89
Most Recent Unit/Department* This field is required.
90
Typical Patient Ratio
91
Patient Populations* This field is required.
Adult
Geri
Peds
Neonatal
Mixed
92
EMR Experience* This field is required.
Epic
Cerner
Meditech
Allscripts
eClinicalWorks
NextGen
Other
93
Other EMR
94
Assignment Type* This field is required.
Per Diem/PRN
Local Contract
Travel Contract
Temp-to-Perm
Permanent
95
Preferred Setting(s)* This field is required.
Acute Care
ICU/Stepdown
ED
OR/PACU
L&D/PP/NICU
Med-Surg/Tele
Behavioral
SNF/Rehab
Home Health
Dialysis
Ambulatory/Clinic
School
Corrections
Other
96
Preferred Shift(s)* This field is required.
Days
Evenings
Nights
Rotating
97
Schedule Availability* This field is required.
Weekdays
Weekends
Holidays
On-call
98
Earliest Start Date* This field is required.
Date
Month
Day
Year
99
Desired Weekly Hours* This field is required.
Please Select
Please Select
8
12
24
36
40+
100
Willing to Float (within competency)* This field is required.
Yes
No
Case-by-case
101
Maximum preferred commute/travel radius
Please Select
Please Select
5 mi
10 mi
20 mi
30 mi
50 mi
75 mi
100 mi
102
Willing to Relocate* This field is required.
Yes
No
Maybe
103
Minimum acceptable hourly rate (optional)
104
Geographic Preferences
105
RTO (Requested Time Off) – next 60 days
106
SPD Certification Type* This field is required.
Please Select
Please Select
CRCST
CSPDT
CIS
CHL
Other
107
Certification Number
108
Certification Expiration Date
Date
Month
Day
Year
109
Years of Sterile Processing Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
110
Primary SPD Work Areas* This field is required.
Decontamination
Assembly / Prep & Pack
Sterilization
Case Carts
Instrument Management
High-Level Disinfection
OR Support
111
Instrument Tracking System Experience
112
Most Recent SPD / CSSD Setting
113
SPD Certification Upload (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
114
Preferred contact method* This field is required.
Text/Call
Email
Mail
115
Charisma SPD Staffing & Applicant SMS Consent (Optional)
I agree
116
Charisma SPD Marketing SMS Consent (Optional)
I agree
117
SMS Terms: Message frequency varies. Message and data rates may apply. Reply STOP to unsubscribe and HELP for help. Carriers are not liable for delayed or undelivered messages. Mobile opt-in information and consent will not be sold or shared with third parties or affiliates for their own marketing or promotional purposes. Review Charisma SPD’s Privacy Policy and Terms and Conditions.
118
How did you hear about Charisma SPD?* This field is required.
Website
Google/Search
Social Media
Referral
School/Training Program
Job Board
Recruiter
Returning Applicant
Other
119
Please provide details
120
Credentialing Readiness* This field is required.
Yes
No
121
Reference 1 Name* This field is required.
First Name
Last Name
122
Reference 1 Professional Title / Relationship* This field is required.
123
Reference 1 Organization* This field is required.
124
Reference 1 Phone* This field is required.
125
Reference 1 Email* This field is required.
example@example.com
126
Reference 2 Name
First Name
Last Name
127
Reference 2 Professional Title / Relationship
128
Reference 2 Organization
129
Reference 2 Phone (optional)
Area Code
Phone Number
130
Reference 2 Email
example@example.com
131
Application Status
Application Received
Please Select
Application Received
Under Review
Interview
Credentialing
Cleared
Placement
On Hold
Not Selected
132
Credentialing Status
Not Started
Please Select
Not Started
Pending Documents
In Progress
Complete
Issue/Follow-up Required
133
Application Source (System)
134
Internal Recruiter Notes
135
Applicant Certification* This field is required.
I certify that the information provided in this application is true and complete to the best of my knowledge.
136
LPN Certifications Held (BLS/CPR and other applicable)
BLS
137
Job Control Job ID
138
Job Requisition ID
139
Job Title (System)
140
Facility/Client (System)
141
Job Location (System)
142
Job Application Date
Date
Month
Day
Year
Should be Empty: