Rehab/LTC EXPERIENCE PROFILE

First Name: Last Name:Grad from nursing school:

Degree: RNC N/A Oncology N/A

ACLS N/A Chemotherapy N/A

Charge Nurse Experience:

State of original License:

State of current License:

Phone Number:

Please indicate your level of experience with the following patient groups and clinical skills category according to the number of years of experience indicated below:

CATEGORIES 0, 1, 2, 3

0=No experience
1=limited experience
2=perform with review
3=perform independently

	Patient Groups	0	1	2	3
	Neonate
	Infant
	Children
	Adolescent
	Adult
	Geriatric
CLINICAL SKILLS

Wound Care/Surgical
Wound Care/Medical
Dressing Changes
Skin Accessment
Suture/Staple removal
Cast Care
PICC insertion
Hemiplegia
Paraplegia
Total Joint replacements
Prosthesis Application
Standard extremity braces
TPN protocols & site care
Sliding boards
Stroke precautions
Assistive devices
Discharge planning
Team charting
Stump wrapping
GT/PEG feedings
Oxygen delivery devices
Nebulizer use
Head Injury
Trauma-lacerations
Tracheostomy care
Ventilator
MSDS assessments
UR/Medicare review
Chemotherapy drugs

Rehab/LTC NURSING WORK HISTORY
TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:

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

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