subject_line
Pre-Employment Questionnaire
Requested by:
Tailored Healthcare Staffing
Medical Staffing Options
Next Travel Nursing
Health Carousel
Partner Network
Date:
+
Professional's First Name:
Professional's Last Name:
Professional's Email:
Professional's Mobile Phone:
Are you authorized to work in the U.S. for any employer?
Yes
No
Have you ever had any government-issued license or certification investigated, suspended, or revoked?
Yes
No
If yes, please explain:
Have you ever been named as a defendant in a malpractice, negligence, or other professional liability action?
Yes
No
If yes, please explain:
Do you have any restrictions that would prevent you from performing essential functions in the position you are applying for (i.e., inability to participate in Medicare or Medicaid programs; no active driver’s license, unwilling to relocate, etc.)?
Yes
No
If yes, please explain:
Do you have at least one (1) year of working experience in your profession and at least one (1) year of working experience in your current discipline/specialty?
Yes
No
If no, please explain:
Are there any other voluntary disclosure that you wish to make at this time or believe that the Company needs to be aware of?
Yes
No
If yes, please explain:
AUTHORIZATION STATEMENT
I, the undersigned Healthcare Professional (the “
Professional
”) and employee of Health Carousel Travel Network, LLC (“
HCTN
”), attest that the information disclosed herein is, to the best of my knowledge, truthful, factual, and accurate. I understand and acknowledge that the disclosure of false information is expressly prohibited and the disclosure of false information may incur disciplinary action, up to and including termination of employment. I further understand, in the event that I disclose false information to HCTN, I agree to compensate HCTN for any and all costs or expenses incurred related to or as a result of such falsified disclosure.
I hereby authorize HCTN to release any and all professional credentials, work verifications, skills checklists, OSHA/HIPAA training results, professional competency exams, criminal background checks, drug screen results and/or health information that I have disclosed to or otherwise authorized to be acquired by HCTN to the extent necessary to:
1. allow me to be considered for an assignment at a Client Healthcare Facility (the “
Facility
”); and/or
2. ensure that all required credentials and regulatory documentation are current at all times prior to and during an assignment at a Facility.
By signing where indicated below, I acknowledge that I have read the above Authorization Statement and hereby agree to its terms. I further acknowledge and agree that a scanned, faxed, electronic, or copied signature constitutes an original signature for all purposes.
Professional's Signature:
clear