Temporal Staff Application Form

Full Name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Date

Social Security Number (SSN)Please type N/A if not available

Phone Number* This field is required.

Please enter a valid phone number.

Email Address* This field is required.

example@example.com

Consent to be contacted by text message or phone call?* This field is required.

I Agree

I Do Not Agree

Preferred Contact Method* This field is required.

Text Message

Phone Call

Driver’s License Issued?* This field is required.

Yes

Driver’s License Number* This field is required.Please type N/A if not available

Address* This field is required.Note: No PO Box

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Preferred Shift(s)

Day

Evening

Night

Weekend

Other

Certifications Held* This field is required.

CRCST

CBSPD

CIS

CER

CHL

Other

Certification Details

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

CRCST

CSPDT

CFSPDT

CER

BLS

Other

CRCST

CSPDT

CFSPDT

CER

BLS

Other

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

Issuer (e.g., HSPA)

Expiration (MM/YYYY)

Other Certification Name* This field is required.Please type N/A if not available

Other Certification Expiration* This field is required.Please type N/A if not available

Date

Have you completed a sterile processing training program?* This field is required.

Yes

Program Name* This field is required.Please type N/A if not available

Program Completion Date* This field is required.Please type N/A if not available

Date

Do you have High Level Disinfection (HLD) endoscope reprocessing experience?* This field is required.Please type N/A if not available

Yes

Scope brands/types (describe)Please type N/A if not available

Reprocessing methods used

Manual HLD (Cidex OPA)

Steris AER

Trophone

Medivator

Olympus HLD System

Astra VR System

ASP

Other

Other reprocessing method* This field is required.Please type N/A if not available

Total SPD Experience* This field is required.Please type N/A if not available

Primary Area of Expertise* This field is required.

Total years of experience in the area* This field is required.

Name of Most Recent Facility You Have Worked* This field is required.Please type N/A if not available

Facility Type* This field is required.

Most Recent Title* This field is required.

Service Lines Supported

Ortho

Neuro

Spine

General

OB/GYN

ENT

Urology

Robotics

Endoscopy

Dental

Other

Tracking/Traceability Systems Used* This field is required.

SPM

CensiTrac

T-DOC

Epic OpTime

Cerner

Meditech

Other

Other tracking system* This field is required.

CSP Skills & Competency Matrix (rate skill level)* This field is required.

Endoscope Skills Matrix (rate skill level)

Employment History (last 3 employers)* This field is required.

Professional References* This field is required.

Have you ever been convicted of a felony?* This field is required.

Yes

If yes, please explain* This field is required.

Are you authorized to work in the US?* This field is required.

Yes

Do you want to upload documents now?* This field is required.

Yes

Resume/CV (PDF/JPG/PNG only, please ensure documents are legible)* This field is required.

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Select files to upload

Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Government-issued photo ID (front) - Please upload a clear, legible image (PDF/JPG/PNG)

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Select files to upload

Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Ensure the front of your ID is clearly visible.

Government-issued photo ID (back) - Please upload a clear, legible image (PDF/JPG/PNG)

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Select files to upload

Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Ensure the back of your ID is clearly visible.

Work Authorization Document (if applicable)

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Certification(s)

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Additional Document 1

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Additional Document 2

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Additional Document 3

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Additional Document 4

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

Additional Document 5

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Max. file size: 10.0MB

Accepted file types: PDF, JPG, PNG. Please upload clear and legible documents.

I certify that the information provided is true and complete to the best of my knowledge.* This field is required.This attestation is required before signing to confirm the accuracy of your information.

Signature* This field is required.

Temporal Staff Application Form – Charisma SPD