RESPIRATORY THERAPY EXPERIENCE PROFILE

First Name: Last Name:Grad from school:

Degree: RNC N/A Oncology N/A

ACLS N/A BLS(same as CPR) 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

Nebulizers
IPPB
Ventilator-Adult
Ventilator-Neonate
Ventilator-child
CPT adult
CPT infant
All oxygen therapies
Oxy hood
Mist tent
Bipap
Trach MGMT
Holter Monitor
12 Lead EKG
Pulmonary function studies
Trauma Center Level 1
Trauma Center Level 2
Trauma Center Level 3
Sleep studies
Code Blue Infant
Code Blue Child
Code Blue Adult
TB pt experience
Intubation, assist
Intubation, perform
Extubation, assist
Extubation, perform

RESPIRATORY THERAPY 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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