Healthcare Staffing Application

1
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 and Instrument Support
Patient Transport
Environmental Services (EVS)
Administrative and Support
Other
2
Please specify the role
3
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
4
LPN License Number
5
LPN License Expiration Date
Date
Month
Day
Year
6
Any restrictions/discipline on LPN license?
Yes
No
7
Explanation if yes
8
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
9
School Name (LPN)
10
Graduation Date (LPN)
Date
Month
Day
Year
11
LPN Certifications Held (BLS/CPR and other applicable)
BLS
12
LPN license verification — state Office of the Professions printout (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload each document once.
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13
Please provide accurate information for healthcare staffing opportunities with Charisma SPD. Upload only job-related qualifications in this application. Do not upload government identity documents, Social Security cards, I-9 or tax forms, pay stubs, W-2s, banking information, medical or immunization records, drug-screen results, or criminal-background reports. Sensitive onboarding information is handled separately if you advance.
14
Full Name* This field is required.
First Name
Last Name
15
Preferred Name
16
Email* This field is required.
example@example.com
17
Mobile Phone (Primary)* This field is required.
Please enter a valid phone number.
18
Phone (Alternate) (optional)
19
Are you legally authorized to work in the United States?* This field is required.
Yes
No
20
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
21
Reliable Transportation* This field is required.
Yes
No
22
Do you have Driver’s License?
Yes
No
23
Languages Spoken
English
Spanish
Chinese
French
German
Hindi
Arabic
Russian
Portuguese
Japanese
Other
Other
24
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
25
CNA Certification/License Number
26
CNA Expiration Date
Date
Month
Day
Year
27
BLS/CPR or Other Certifications
BLS/CPR
ACLS
PALS
Other
Other
28
Years of CNA/Patient Care Experience
Please Select
Please Select
<1
1–2
3–5
6–10
10+
29
Primary Healthcare Setting
30
Most Recent Unit/Department
31
Patient Population Experience
Adult
Geriatric
Pediatric
Neonatal
Mixed
Other
Other
32
CNA certificate or Nurse Aide Registry verification (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload your CNA certificate or a printout of your Nurse Aide Registry listing. Upload each document once.
Cancelof
33
Relevant Certification Type
Please Select
Please Select
CER
CRCST
CSPDT
Other
34
Certification Number
35
Certification Expiration Date
Date
Month
Day
Year
36
Years of Endoscope Reprocessing Experience
Please Select
Please Select
<1
1–2
3–5
6–10
10+
37
Endoscope Reprocessing Experience Areas
Manual Cleaning
Leak Testing
High-Level Disinfection
Sterilization
Drying/Storage
38
AER/Reprocessing Equipment Experience
39
Most Recent Endoscopy/SPD Setting
40
Endoscope reprocessing certificate — CFER, CER or manufacturer training (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload each document once.
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41
Years of OR/Instrument Support Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
42
Surgical Specialties Supported* This field is required.
General Surgery
Orthopedics
ENT
Neuro
Cardiovascular
Urology
GYN
Plastics
Robotics
Other
Other
43
Experience Areas* This field is required.
Case Carts
Instrument Sets
Room Support
Loaners
Other
Other
44
Most Recent OR/Perioperative Setting
45
Relevant Certifications
46
OR / surgical support certificate (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
For example CST, CRCST or OR assistant training. Upload each document once.
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47
Years of Patient Transport/Healthcare Support Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
48
Healthcare Setting Experience
49
BLS/CPR if held
50
Experience with Wheelchairs/Stretchers/Bed Transport* This field is required.
Wheelchairs
Stretchers
Bed Transport
51
Patient Safety Protocol Experience
52
BLS/CPR card or patient transport training certificate (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload each document once.
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53
Years of Healthcare EVS Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
54
Facility/Department Setting
55
EVS Experience Areas* This field is required.
Routine Cleaning
Discharge/Terminal Cleaning
Isolation-Room Cleaning
Infection-Prevention Procedures
56
Relevant Training/Certifications
57
EVS or infection-control training certificate (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload each document once.
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58
Years of Healthcare Administrative/Support Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
59
Healthcare Setting
60
Areas of Experience* This field is required.
Scheduling
Front Desk
Data Entry
Patient Access
Office Support
Inventory
Coordination
Other
Other
61
Software/EMR Systems Experience
62
Relevant Certifications
63
Administrative or medical office certificate (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload each document once.
Cancelof
64
Years of Relevant Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
65
Most Recent Work Setting
66
Relevant Licenses/Certifications
67
Short Summary of Qualifications
68
License or certificate for the role you entered (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload each document once.
Cancelof
69
Will you now or in the future require employer sponsorship to work in the United States?* This field is required.
Yes
No
70
RN License Type* This field is required.
Compact
Non-Compact
Pending
71
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
72
License Number* This field is required.
73
License Expiration Date* This field is required.
Date
Month
Day
Year
74
Any restrictions/discipline on any license?* This field is required.
Yes
No
75
Comments / Explanation (Restrictions or Discipline) (if applicable)
76
Highest Nursing Degree* This field is required.
Please Select
Please Select
ADN
BSN
MSN
DNP
Other
77
Nursing School Name (RN)* This field is required.
78
Graduation Date (RN)* This field is required.
Date
Month
Day
Year
79
Certifications Held* This field is required.
BLS
ACLS
PALS
NRP
TNCC
ENPC
NIHSS
CPI
Chemo
Moderate Sedation
Other
80
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
81
Other Certification Name* This field is required.
82
Other Certification Expiration* This field is required.
Date
Month
Day
Year
83
Total RN Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
84
Do you want to upload documents now?
Yes
No
85
Resume / CV
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload your résumé here only — not in the certificate boxes.
Cancelof
86
High school diploma or GED
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload your high school diploma, GED or equivalent. For a foreign diploma, add your WES/ECE evaluation in the Other certificates box.
Cancelof
87
Recent work history (only if you are not uploading a résumé): employer, title, and dates for your two most recent jobs
88
RN license verification — state Office of the Professions printout (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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89
BLS / CPR card (ACLS / PALS too if you have them)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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90
Other certificates — e.g. BLS/CPR, HIPAA, WES education evaluation (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Only documents you did not already upload above. Upload each document once.
Cancelof
91
We use this to verify your work history. Résumé still welcome.
92
Job 1 – Employer / facility name* This field is required.
93
Job 1 – Job title* This field is required.
94
Job 1 – City, State* This field is required.
95
Job 1 – Start date* This field is required.
Date
Month
Day
Year
96
Job 1 – End date
Date
Month
Day
Year
97
Job 1 – I currently work here
I currently work here
98
Job 1 – Supervisor or HR contact name
99
Job 1 – Contact email
example@example.com
100
Job 1 – Contact phone
Please enter a valid phone number.
101
Job 1 – May we contact this employer to verify?* This field is required.
Yes
No
Only after an offer
102
Job 2 – Employer / facility name
103
Job 2 – Job title
104
Job 2 – City, State
105
Job 2 – Start date
Date
Month
Day
Year
106
Job 2 – End date
Date
Month
Day
Year
107
Job 2 – I currently work here
I currently work here
108
Job 2 – Supervisor or HR contact name
109
Job 2 – Contact email
example@example.com
110
Job 2 – Contact phone
Please enter a valid phone number.
111
Job 2 – May we contact this employer to verify?
Yes
No
Only after an offer
112
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
113
Years in Primary Specialty* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
114
Most Recent Unit/Department* This field is required.
115
Typical Patient Ratio
116
Patient Populations* This field is required.
Adult
Geri
Peds
Neonatal
Mixed
117
EMR Experience* This field is required.
Epic
Cerner
Meditech
Allscripts
eClinicalWorks
NextGen
Other
118
Other EMR
119
Assignment Type* This field is required.
Per Diem/PRN
Local Contract
Travel Contract
Temp-to-Perm
Permanent
120
Preferred Setting(s)* This field is required.
Central Sterile (SPD / CSSD)
Endoscopy Unit
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
121
Preferred Shift(s)* This field is required.
Days
Evenings
Nights
Rotating
122
Schedule Availability* This field is required.
Weekdays
Weekends
Holidays
On-call
123
Earliest Start Date* This field is required.
Date
Month
Day
Year
124
Desired Weekly Hours* This field is required.
Please Select
Please Select
8
12
24
36
40+
125
Willing to Float (within competency)* This field is required.
Yes
No
Case-by-case
126
Maximum preferred commute/travel radius
Please Select
Please Select
5 mi
10 mi
20 mi
30 mi
50 mi
75 mi
100 mi
127
Willing to Relocate* This field is required.
Yes
No
Maybe
128
Minimum acceptable hourly rate (optional)
129
Geographic Preferences
130
RTO (Requested Time Off) – next 60 days
131
I am not certified yet / still completing my CRCST training
132
SPD Certification Type* This field is required.
Please Select
Please Select
CRCST
CSPDT
CIS
CHL
Other
133
Certification Number
134
Certification Expiration Date
Date
Month
Day
Year
135
Years of Sterile Processing Experience* This field is required.
Please Select
Please Select
<1
1–2
3–5
6–10
10+
136
Primary SPD Work Areas* This field is required.
Decontamination
Assembly / Prep & Pack
Sterilization
Case Carts
Instrument Management
High-Level Disinfection
OR Support
137
Instrument Tracking System Experience
138
Most Recent SPD / CSSD Setting
139
Are you fully certified in sterile processing?* This field is required.
Yes — fully certified (CRCST, CBSPD CSPDT or equivalent)
Provisional — I passed the exam and am completing my hands-on hours
No — still in training or I haven't passed the exam yet
140
SPD certificate — CRCST, CBSPD CSPDT, CER, CIS or CHL
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload your sterile processing certificate or the HSPA/CBSPD verification page. Upload each document once — your résumé goes in the Résumé / CV box.
Cancelof
141
Preferred contact method* This field is required.
Text/Call
Email
Mail
142
Charisma SPD Staffing & Applicant SMS Consent (Optional)
I agree
143
Charisma SPD Marketing SMS Consent (Optional)
I agree
144
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.
145
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
146
Please provide details
147
Credentialing Readiness* This field is required.
Yes
No
148
Please list two professional references. At least one should be a direct supervisor or manager from the last 2–3 years. We contact references only with your authorization.
149
Reference 1 Name* This field is required.
First Name
Last Name
150
Reference 1 relationship type* This field is required.
Please Select
Please Select
Direct supervisor / manager
Coworker / peer
Instructor / clinical preceptor
Other professional contact
151
Reference 1 Professional Title / Relationship* This field is required.
152
Reference 1 Organization* This field is required.
153
Reference 1 Phone* This field is required.
154
Reference 1 Email* This field is required.
example@example.com
155
Reference 2 Name* This field is required.
First Name
Last Name
156
Reference 2 relationship type* This field is required.
Please Select
Please Select
Direct supervisor / manager
Coworker / peer
Instructor / clinical preceptor
Other professional contact
157
Reference 2 Professional Title / Relationship* This field is required.
158
Reference 2 Organization* This field is required.
159
Reference 2 Phone* This field is required.
Area Code
Phone Number
160
Reference 2 Email* This field is required.
example@example.com
161
Reference authorization
I authorize Charisma SPD to contact the professional references I have listed to verify my employment history and job performance.
162
Application Status
Application Received
Please Select
Application Received
Under Review
Interview
Credentialing
Cleared
Placement
On Hold
Not Selected
163
Credentialing Status
Not Started
Please Select
Not Started
Pending Documents
In Progress
Complete
Issue/Follow-up Required
164
Application Source (System)
165
Internal Recruiter Notes
166
Are you willing to complete a background check and drug screen if offered an assignment?
Yes
No
167
Can you provide immunization records and current TB test results during onboarding?
Yes
No
168
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.
169
Applicant signature* This field is required.
170
Signed on* This field is required.
Date
Month
Day
Year
171
Job Control Job ID
172
Job Requisition ID
173
Job Title (System)
174
Facility/Client (System)
175
Job Location (System)
176
Job Application Date
Date
Month
Day
Year
Should be Empty: