Application Materials

The following documents and licenses are required and must be on file for all Nurse Agency nurses.

To Download a form, click on the link. You must have the Acrobat Reader to view most of these documents. You may download the Acrobat Reader here.

1.Application Documentation:

• Application for Employment
• Employment Verification form (Please complete two (2) forms)
• Employment Eligibility Form
• State W-4 form
• Federal W-4 Form
• Two professional references (one is required to be a Charge RN or Manager who can evaluate your skills).
• OSHA Exam
• Age Appropriate Exam
• Hepa Mask Waiver Form
• HIPAA Confidentiality Form
• Criminal Background Check Form
• Skills Checklist (please complete the skills checklist that applies to your specialty. If you have more than one specialty, please complete all checklists that apply):

  Critical Care Skills Checklist

  Emergency Room Skills Checklist

  Medical/Surgical Skills Checklist

2. Health Requirements

• Physician form or physician statement
• Hepatitis B documentation (vaccination series, titer, or signed declination).
• A TB Test from the past twelve months or a Chest X-Ray within five years.
• TB Questionnaire Only complete this if you test positive for TB.
• Proof of Immunity to Rubeola and Rubella and Mumps (positive titer or MMR within ten years). Please note: Not all hospitals require the Mumps titer.
• Positive Varicella titer or history of the disease
• Urine drug screen

3. Licenses and Certifications

• A current Illinois or Indiana Nursing License.
• A current CPR card.
• Proof of eligibility to work in the United States (Social Security card and Driver's License or Passport or Birth Certificate).

All of the above items must be in your file before you will be permitted to work.

Back to Home Page