EagleWings Allied Health — FCPS Private Duty Nursing Application

EagleWings Allied Health — FCPS Private Duty Nursing Application

Complete this 15–20 minute form to determine eligibility for placement under our FCPS Private Duty Nursing contract.
Section 1 — Contact & Basic Information
Full legal first name

First NameLast Name
Full legal middle name
Full legal last name
Preferred name
Date of birth

MonthDayYear
Email address
example@example.com
Mobile phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate phone
Please enter a valid phone number.Format: (000) 000-0000.
Home street address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip code
Approximate driving distance from Frederick MD
How did you hear about EagleWings
Section 2 — Credentials & Licensing
Which credentials do you currently hold
Maryland Nursing License number
Maryland license expiration date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is your Maryland license currently in good standing
If your license is not in good standing please explain
Do you hold nursing licenses in other states
If yes list state and license number
Current CPR certification level
CPR certification expiration date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional certifications
Upload copy of Maryland nursing license

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Upload copy of CPR card

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Section 3 — Clinical Experience
Total years of nursing experience
Years of pediatric experience
Have you worked in a school-based nursing setting before
If yes, describe your school-based experience
Have you previously worked with FCPS, MCPS, BCPS, or another Maryland public school system
If yes, provide details
Specialty skills (check all that apply)
Are you comfortable with one to one student assignments
Section 4 — Availability
Days available
Preferred work schedule
Interested in FCPS Extended School Year summer program
Willing to serve as substitute or backup nurse
Maximum distance willing to travel from home
Willing to be assigned to Frederick County schools specifically
Earliest start date available

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Section 5 — Maryland School Employment History MSDE 6-113.2
Have you worked in any Maryland school system before?
If yes, list all prior Maryland school employers with dates of employment and position held.
Have you ever worked for a contracted staffing agency that placed you in a school setting?
If yes, describe the agency and placement.
Section 6 — Employment Eligibility
Section 7 — Background & Character Disclosures
Section 8 — Physical Capability Attestation
FCPS requires PDN staff to lift up to 50 lbs. OSHA transfer limits apply — single-person maximum 35 lbs, two-person maximum 70 lbs.
Can you lift up to 50 lbs
Do you understand OSHA transfer limits and agree to follow them
Do you have any physical limitations that would affect your ability to provide Activities of Daily Living support to a student
If yes, please describe
Section 9 — Professional Liability Insurance
Do you currently maintain your own professional liability or malpractice insurance
Insurance carrier name
Policy number
Coverage limits
Policy expiration date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If no, I acknowledge that EagleWings Allied Health will cover me under agency policies during my assignment
FCPS runs its own criminal background check via fingerprinting at their HR office. Truthful disclosure here is required. Undisclosed history discovered later is grounds for immediate disqualification and termination.
Are you currently a registered sex offender in any state
Have you ever been convicted of any crime other than a minor traffic violation
If yes, provide details
Have you ever been the subject of a substantiated finding of child abuse, neglect, or sexual misconduct
Has your professional nursing license ever been revoked, suspended, or restricted in any state
If yes, please explain
Have you ever been terminated from a nursing position for cause
If yes, please explain
Are you currently subject to any pending disciplinary action from any nursing board
Are you legally eligible to work in the United States?
Do you understand you will need to complete Form I-9 with acceptable identity and work authorization documents upon hire?
Section 10 — Professional References
Please provide three professional references.
Reference 1 — Most Recent Supervisor
Full name
Title
Employer or organization
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Professional relationship
Years known
Reference 2 — Prior Clinical Manager or Supervisor
Full name
Title
Employer or organization
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Professional relationship
Years known
Reference 3 — Peer Colleague or Educator
Full name
Title
Employer or organization
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Professional relationship
Years known
Section 11 — Acknowledgements & Signature
Please review and acknowledge each item below. All acknowledgements are required.
I understand that FCPS runs its own fingerprinting appointment through FCPS Human Resources and I will report in person to 191 South East Street, Frederick, MD on the scheduled date.
I understand that I will sign a student-specific Memorandum of Understanding for each student assignment.
I understand that required trainings including school-based nursing orientation are provided by EagleWings and I agree to complete them as a condition of assignment.
I understand this is temporary staffing tied to the FCPS school year and does not guarantee continuous or year-round employment.
I understand I will be classified as at-will, non-exempt, hourly.
I understand I will not communicate directly with the student's parent or guardian during the school day; all communication routes through FCPS School Health Staff.
I attest that all information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that misrepresentation is grounds for immediate disqualification or termination.
Electronic signature
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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EagleWings Allied Health — FCPS Private Duty Nursing Application

Section 1 — Contact & Basic Information

Section 2 — Credentials & Licensing

Section 3 — Clinical Experience

Section 4 — Availability

Section 5 — Maryland School Employment History MSDE 6-113.2

Section 6 — Employment Eligibility

Section 7 — Background & Character Disclosures

Section 8 — Physical Capability Attestation

Section 9 — Professional Liability Insurance

Section 10 — Professional References

Reference 1 — Most Recent Supervisor

Reference 2 — Prior Clinical Manager or Supervisor

Reference 3 — Peer Colleague or Educator

Section 11 — Acknowledgements & Signature