SURGERY/RECOVERY-
NURSES ADMINISTRATION
Training Checklist

Name:
  (Last)   (First)   (MI)
Phone Number (with area code):

Social Security Number:  

Email Address

Please indicate your level of proficiency in each area by selecting the appropriate button.

NURSING ADMINISTRATION HOUSE SUPERVISOR   Perform Independently   Perform with review   Limited or no experience   None Selected NURSE EXECUTIVE   Perform Independently   Perform with review   Limited or no experience   None Selected NURSE RECRUITING   Perform Independently   Perform with review   Limited or no experience   None Selected NURSING EDUCATION   Perform Independently   Perform with review   Limited or no experience   None Selected RISK MANAGEMENT   Perform Independently   Perform with review   Limited or no experience   None Selected

Authorization (Please type your name and the date.)

By submitting this application, I hereby certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

Signature   Date