Charisma SPD – Employment/Agency Onboarding (Required)

1
Full Legal Name* This field is required.
First Name
Last Name
2
Preferred Name
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email Address* This field is required.
example@example.com
5
Current Address* This field is required.
Street Address
Street Address Line 2
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
6
Employment Type / Pay Type* This field is required.
W-2 Employee (Agency Payroll)
1099 / Independent Contractor
7
Emergency Contact Full Name* This field is required.
First Name
Last Name
8
Emergency Contact Relationship* This field is required.
9
Emergency Contact Phone* This field is required.
Please enter a valid phone number.
10
Emergency Contact Alternate Phone
Please enter a valid phone number.
11
Emergency Contact Email
example@example.com
12
Facility / Client Name* This field is required.
13
Unit / Department* This field is required.
Please Select
Please Select
Central Sterile (SPD)
OR Support
Endoscopy/GI
Ambulatory/Clinic
Other
14
Specify Unit* This field is required.
15
Position / Title* This field is required.
Please Select
Please Select
SPD Tech I
SPD Tech II
SPD Tech III
Lead
Supervisor
Other
16
Specify Title* This field is required.
17
Assignment Type* This field is required.
Per Diem
Temp
Local Contract
Temp-to-Perm
18
Shift* This field is required.
Days
Evenings
Nights
19
Shift Hours* This field is required.
20
Days Scheduled* This field is required.
Mon
Tue
Wed
Thu
Fri
Sat
Sun
21
Start Date* This field is required.
Date
Month
Day
Year
22
Expected End Date
Date
Month
Day
Year
23
Reporting Instructions
24
Pay Rate ($/hr)* This field is required.
25
Overtime Rate ($/hr)
26
Pay Schedule* This field is required.
Weekly
Biweekly
27
Timekeeping Method* This field is required.
Facility timesheet approval
Agency timesheet/app
Both
28
Timesheet Deadline* This field is required.
Every Sunday by 6 PM
End of shift (daily)
Other
29
Timesheet Deadline Details* This field is required.
30
I understand I must arrive on time and follow facility attendance policies.* This field is required.
I understand I must arrive on time and follow facility attendance policies.
31
If I cannot work a scheduled shift, I will notify BOTH the facility/unit and Charisma SPD as early as possible.* This field is required.
If I cannot work a scheduled shift, I will notify BOTH the facility/unit and Charisma SPD as early as possible.
32
No-Call/No-Show may result in immediate removal from assignment and termination of eligibility for future placements.* This field is required.
No-Call/No-Show may result in immediate removal from assignment and termination of eligibility for future placements.
33
Late cancellations may result in removal from the schedule and/or disciplinary action per facility and agency policy.* This field is required.
Late cancellations may result in removal from the schedule and/or disciplinary action per facility and agency policy.
34
If the facility cancels my shift, Charisma SPD will notify me as soon as possible; cancellation pay depends on facility policy and applicable labor rules.* This field is required.
If the facility cancels my shift, Charisma SPD will notify me as soon as possible; cancellation pay depends on facility policy and applicable labor rules.
35
Assignment Acceptance* This field is required.
Yes, I accept this assignment/offer as listed above
No, I do not accept
36
Reason for not accepting assignment* This field is required.
37
Assignment not accepted. Charisma SPD will contact you.
38
Payment Method* This field is required.
Direct Deposit
Paper Check
39
Bank Name* This field is required.
40
Account Holder Name* This field is required.
41
Routing Number (9 digits)* This field is required.
42
Account Number* This field is required.
43
Account Type* This field is required.
Checking
Savings
44
Upload Voided Check or Bank Letter* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
45
I authorize Charisma SPD to deposit my pay to the account listed above. I understand I am responsible for providing accurate banking details.* This field is required.
I authorize Charisma SPD to deposit my pay to the account listed above. I understand I am responsible for providing accurate banking details.
46
Upload W-4 (Federal)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
47
Upload State/Local Withholding Form* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
48
Tax Form Completion Method* This field is required.
Upload completed forms here
I will complete in-office (within 24–48 hours)
I will complete via secure payroll portal
49
I understand payroll may be delayed if tax forms are not completed on time.* This field is required.
I understand payroll may be delayed if tax forms are not completed on time.
50
I will maintain respectful communication and professional behavior with patients, staff, and visitors.* This field is required.
I will maintain respectful communication and professional behavior with patients, staff, and visitors.
51
I will follow the facility’s policies, dress code, ID/badge requirements, and scope-of-practice rules.* This field is required.
I will follow the facility’s policies, dress code, ID/badge requirements, and scope-of-practice rules.
52
I will protect patient privacy and follow HIPAA and facility confidentiality rules.* This field is required.
I will protect patient privacy and follow HIPAA and facility confidentiality rules.
53
I will not take photos/videos inside the facility and will not post work-related content on social media.* This field is required.
I will not take photos/videos inside the facility and will not post work-related content on social media.
54
I will report injuries, exposures, hazards, and policy concerns immediately to the facility and Charisma SPD.* This field is required.
I will report injuries, exposures, hazards, and policy concerns immediately to the facility and Charisma SPD.
55
I will not report to work under the influence of alcohol, illegal drugs, or impairing substances.* This field is required.
I will not report to work under the influence of alcohol, illegal drugs, or impairing substances.
56
Upload Headshot / Badge Photo* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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57
Internal Use Consent* This field is required.
I consent to use of my photo for internal identification/badge purposes only
58
Marketing/Promotional Photo Consent
Yes
No
59
I understand I can revoke this consent in writing at any time.
I understand I can revoke this consent in writing at any time.
60
Typed Full Legal Name* This field is required.
61
Signature* This field is required.
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62
Date Signed* This field is required.
Date
Month
Day
Year
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