Application Materials

The following documents and licenses are required and must be on file for all employees. Please call us to schedule an appointment. We do not accept walk-in appointments.

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 (I-9 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) Please give us both home and work numbers.
• OSHA Review Packet
  • OSHA Test: Paper Version (Click here to print out the test, complete it, and mail or fax it to us)
  • OSHA Test: E-Form (Click here to complete the test online and send it to us via your email account)
• Age Appropriate Review Packet
  • Age Appropriate Test: Paper Version (Click here to print out the test, complete it, and mail or fax it to us)
  • Age Appropriate Test: E-Form (Click here to complete the form online and send it to us via your email account)
• HIPAA Confidentiality Form
• Hepa Mask Waiver Form
• Criminal Background Check
• Hospital Client Checklist

• Skills Checklist: Paper version. Please print out, complete and mail or fax 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

  Labor and Delivery and Mother/Baby Skills Checklist

  Neonatal Intensive Care Skills Checklist

  Pediatric Skills Checklist

  Pediatric Intensive Care Skills Checklist

  Certified Nursing Assistant

• Skills Checklist: E-Form version. Please complete the form on-line and then e-mail the form to us by saving it to your computer and then attaching the form to an e-mail addressed to ann@thenurseagency.com. 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

Labor and Delivery and Mother/Baby Skills Checklist

Neonatal Intensive Care Skills Checklist

Pediatric Skills Checklist

2. Health Requirements

• A physical or physicians statement from the past twelve months (annual requirement)
• Hepatitis B Documentation (vaccination series, titer, or signed declination)
• A TB test from the past twelve months of a Chest X-Ray within five years (annual requirement)
• 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).
• Positive Varicella titer
• Urine drug screen

3. Licenses and Certifications

• A current Illinois or Indiana Nursing License or CNA Certification
• A current CPR/ACLS card (only American Heart Association Cards are accepted)
• 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.

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