Pre-Employment Questionnaire

Requested by:

Requested by email:

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

Have you ever had any government-issued license or certification investigated, suspended, or revoked?

Yes

If yes, please explain:

Have you ever been named as a defendant in a malpractice, negligence, or other professional liability action?

Yes

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

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

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

If yes, please explain:

Your permanent tax home status is an important factor in providing you with an IRS compliant pay package. Please click here for more information and assistance in determining your tax home status. If you maintain a permanent tax residence, you will be asked to provide proof of address prior to the start of an assignment. For a list of acceptable proof documents, click here.

YES - I maintain a permanent tax residence

NO - I do not maintain a permanent tax residence

Street Address

City/State/Zip

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