Nurse Applicant Questionnaire PhoneRN 2018

Thank you for your interest in our Triage position. In order to complete our preliminary evaluation, please fill out the form below and attach your resume. This should take less than five minutes to complete. Once we have the additional information we will review that along with your resume.

Today's Date +

Last Name *

First Name *

State Of Residence * 🛈

Your Nursing License Number: *

Why are you interested in remote telephone triage? *

Which days and hours are you currently working? *

Please attach your resume here. *

Please attach a list of your references. *

Phone Number *

Email Address *

Registered Nurse (at this time, we do not hire LPN or NP)

Please list state(s) you are currently licensed in: *

How many years of Nursing experience do you have? *

Less than 3 years

3 to 5 years

5 to 10 years

More than 10 years

Previous employment and rates of pay will be verified except in states where prohibited by law.

Current or most recent pay rate (NY state residents enter N/A) *

Do you have any telephone triage experience? *

Yes

No

If yes - please describe relevant telephone triage experience in more detail

If no - please describe any experience or skill sets that you feel would allow you to become a good triage nurse *

What best describes the amount of hours willing to work in a week? *

8 to 12

12 to 20

20 to 32

More than 32

What time(s) of week are you willing to work? *

Monday to Friday Evenings

Monday to Friday Overnight

Saturday/Sunday: Daytime

Saturday/Sunday: Overnight

What time(s) of week are you not able to work?

Monday to Friday Evenings

Monday to Friday Overnight

Saturday/Sunday: Daytime

Saturday/Sunday: Overnight

Please tell us how you heard about us: Craigslist, Indeed, Newspaper, Word of mouth, etc. *