Employment Application
North Carolina
Name
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Licensure Type
Please Select
Registered Nurse
Paramedic
License Number
State of Licensure
Expiration Date of Licensure
BLS/ACLS Certification
Please Select
BLS only
ACLS/BLS Certified
Not Certified
Years of Experience/ Describe IV Experience
Employment History (Most Recent First)
Professional References (2 minimum)
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IV Skills Assessment
Describe your approach to a difficult IV stick
What gauge catheter do you prefer and why?
How do you respond if you blow a vein?
Clinical signs of infiltration vs. extravasation?
How would you handle an anxious client?
Type a question
Ratee your IV confidence (1-10)
Please Select
1
2
3
4
5
6
7
8
9
10
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