First Name:                 Last Name:           SSN #:

    Address:        city      
 state        zip        EMail: 
Telephone:        Home:        Work:        Mobile:
Educational Background: (Highest Level of Education)
Name of School:                              Degree:
Professional Background:
Medical Technologist:        Cytologist:        Histologist:        Medical Technician:        Other:
Certification:
                      ASCP:               NCA:               AMT:                           AACC:        Other:
Licensure:
State: :        Type/Level:        State:        Type/Level: :        
Technical Experience:
Supervisory:       Bench:       Research:        Generalist:        Specialist:
Please indicate the number of YEARS experience in each category:
       Hematology:  Chemistry: Microbiology:   Immunology: Blood Bank:
       Coagulation: Toxicology:     Parasitology: Bio-Hazardous:    Transfusion:
                  U/A:           EIA:          Virology:           Serology:            Donor:
Flow Cytometry:           RIA:       Phlebotomy:
Other (Specify):               Other (Specify):
Lab Computer System(S) (Specify)
Please list instrumentation you are experienced in operating:
Employment History:

Current Employer:
    Address: city state zip                                  
Your Job Title: How Long Employed: Rate:
Shift / Hours per week:

Previous Employer:
    Address: city state zip                                  
Your Job Title:  How Long Employed: Reason for leaving:              
Work Preference: How can LAB FORCE be of service to you?
Geographic Preference:      Shift/ Hours Preference:
Work Environment Preference: Hospital: Reference Lab: POL: Industry: Other:

I understand the information above will be kept confidential as part of my LABFORCE file. This information will be released only at my request or as required for employment.

                                                                      
I agree                                                                   Date:

 

 

      

BACTERIOLOGY BLOOD SERVICES
General Diagnostic Immunohematology
  Collection
MYCOBACTERIOLOGY  
General  
VIROLOGY HISTOPATHOLOGY
General General
Limited Oral Pathology
Mycology Dermatopathology
Parasitology Exfoliative Cytology
DIAGNOSTIC IMMUNOLOGY HISTOCOMPATIBILIY
General General
Rubella Paternity Testing
Hepatitis Inherited Metabolic Disease
HIV/HTLV-III/LAV Screen Radiobioasay
HIV/HTLV-III/LAV Urinalysis
CONFIRMATORY TESTING CELLULAR IMMUNOLOGY
Syphilis Lymphoid Functional Assays
Urine Pregnancy Testing Non-lymphoid Immunophenotyping
Comprehensive Flow Cytometry
CLINICAL CHEMISTRY

        • Non-Lymphoid Functional Assays
General

        • Lymphoid/T-Lymphoid

pH Blood Gases

        • Immunophenotyping
Therapeutic Substance Monitoring ONCOFETAL ANTIGENS
Quantitative Toxicology General SERA only
Endocrinology General Amniotic Fluid
TOXICOLOGY  
Drug Analysis/Qualitative HEMATOLOGY
Emergency Toxicology General
Forensic Toxicology IMMUNOHISTOCHEMISTRY
Blood Lead General Assays
Erythrocyte Protoporphyrin Extraction Cell Culture
Erythrocyte Protoporphyrin Hematoflurometer PCR, DNA sequencing
CYTOGENETICS DNA/RNA Isolation
Specimen Preparation DNA/RNA Characterization
Microscopy  
Photomicroscopy Pipetting, Weighing, Operating pH meters
Computer Image Analysis Centrifugation
Karyotyping Filtration

 

 

      

First Name: Last Name: SSN #:
EMail:   Tel: Home: Work: Mobile:

Address: city state zip    

PROFESSIONAL EXPERIENCE:
RADIOLOGY:
Radiographer: RT:  
Specialty:      
Radiography: MRI: Radiation Therapy: Mammography:
Cardiovascular: CT: Nuclear Medicine: Quality Mngmnt:
SONOGRAPHY/ULTRASOUND:
Registered Diagnostic Cardiac Sonographer: RDCS:
Registered Vascular Technologist: RVT:
Registered Diagnostic Medical Sonographer: RDMS:
Specialty:          Abdominal:            Neuro:             Ob/Gyn:                            Opthalmology:
EDUCATION / LICENSURE:
Degree: Nat’l Cert: /
State License:       as
TECHNICAL EXPERIENCE:
TOTAL YRS IN FIELD: Level: Entry       Staff       Senior       Supervisor
Patient Type: (Years experience with each group)
Pediatric: Adolescent: Adult: Geriatric:
Work Environment: (Years experience in each area)
Acute Care: Rehab: Nursing Home: PSC:
Other: Computer Systems:
EMPLOYMENT HISTORY:

Current (or Previous) Employer:

Current: FT PT N/A Shift: 1 2 3 Total Hrs:  Annual Salary: $  Hourly Rate: $

Address: city state zip                                  
Title: How Long Employed: Rate: Shift / Hours per week: Reason for leaving:

Previous Employer:
    Address:  city state zip                                  
Title:                How Long Employed:                Reason for leaving:              
Previous “Agency” affiliation / work:
Work Preference: How can LAB FORCE be of service to you?
Location: Temp:                  Shift: 1 2 3                Number of Hours:                Desired Rate:
Travel (Contract):           Perm:   FT PT Shift: 1 2 3

Level:                                Salary

                                   
I agree                                 Date

 

 

      

 

Please list any limitations or comments you may have on a separate sheet.

IDENTIFYING
INFORMATION

Last Name

First Name

Middle Name

Previous Surname

 

LIFE SUPPORT
CERTIFICATION

BLS  
Expiration date:

ACLS  
Expiration date:  

OTHER
Expiration date: (mm/dd/yy)

 

EXAMS AND
REGISTRATION

A.R.R.T.

Other:

Registry #:

Exp. Date

Primary Modalities:

Radiation Therapy     Dosimetry

Radiologic Technology

Nuclear Medicine Technology

 

POPULATIONS

Adult

Pediatric

Neonatal

 

LICENSES List all states in which you are or have ever been licensed beginning with your original state license

Original State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

I affirm that all information given on these pages are true and accurate.  

          Initials                         Date

 

CLINICAL SKILLS: Please check the areas below where you have clinical experience within the past 24 months and where you are currently proficient.

 

Cranium

Tx

Simulation

Specialized Equipment

Tx

Simulation

Accelerators (continued)

  Tx

R/L Lateral

Gaiting

Toshiba

Vertex

BAT

Peacock

SRS

HDR

NOMOS

Head & Neck

Tx

Simulation

Vaginal

Gamma Knife

3 field

Bronchial

CO 60

R/L Lateral

Mammosite

Other:

 

5 field Boost

Multiplanar

Tx Planning

Breast

Tx

Simulation

Other:

   

Corvus

Tangents

Accelerators

Helios

S’clav

Varian

Eclipse

PAB

6/100

Plat

IMC

2100 series

Helax

Lung

1800 series

Vaniflex

AP/PA

2300 series

Akribe: a

Oblique

Portal Vision

ACQ Plan

Pelvis

Tx

Simulation

MLCS

ADAC

4 field

Elekta

Other:

AP/PA

Portal Vision

Simulators

Rotational arcs

MLCS

Ximatron

Misc.

Siemens

CT

Extremity

Mevatron

Other:

Spine

KDII

Record & Verify

Abdomen

Primus

Impac

Electron

Portal Vision

Lantis

Total Body

MLCS

Varis

Mantle

Other:

IMRT

Other:

 

Please list any additional skills or procedures you have performed:

 

I affirm that all information given on these pages are true and accurate.  
          Initials                         Date


     

Please list any limitations or comments you may have on a separate sheet.

IDENTIFYING
INFORMATION

Last Name

First Name

Middle Name

Prvs Surname

LIFE SUPPORT
CERTIFICATIONS

BLS  Exp. date:

ACLS Exp. date: 

OTHER Exp. date:

EXAMS AND
REGISTRATION

A.R.R.T.     NMTCB . RCIS .   Other:     Registry #:     Exp. Date (mm/dd/yy)

Primary Modalities: Radiologic Technology             Nuclear Medicine Technology                 Radiation Therapy  

Advanced Modalities Cardiovascular-Interventional Mammography (MQSA qualified? Yes No) CT Scan MRI Qlty Mgt.

LICENSES List all states in which you are or have ever been licensed beginning with your original state license

Origninal State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

State License

License Number

Exp. Date

POPULATIONS

Adult

Pediatric

Neonatal

CLINICAL SKILLS: Please check the areas below where you have clinical experience within the past 24 months and where you are currently proficient.

General Radiology:

Interventional / Spec Proc

CT Studies:

CT Angio:

Skull

Arteriography

Head

Head / Neck

Facial bones

        Extremity

        Brain

Perfusion studies

Sinuses

        Abdominal aortography

        Facial bones

Cardiac

Chest

        Mesenteric

        Sinuses

Pulmonary

Abdomen

        Renal

        Orbit

Abd/Renal/Mesenteric

Spine

        Selective visceral

        Temporal bones / TM Joints

Femoral run off

        Cervical

        Pulmonary

Chest

CT Assisted Procedures:

        Thoracic

Embolization

Neck/Larynx

Bx

        Lumbar

Venography

Spine

Drainage

Hip

Stenting

        Cervical

Aspiration

Pelvis

IVP

        Thoracic

Spinal blocks/ injections

Extremities

Cholangiograms

        Lumbar

Mammography:

Joints

Myelogram

Abdomen:

Film Screens

Shoulder region

Arthrogram

        Routine abdomen

Localizations

Exam Location

IVC Filter

        Liver

Xeromammography

Portable

Interventional/Cardiology:

        Pancreas

Breast Ultrasound

OR

Cardiac Catheterization

        Renal

Ductography

Trauma/ER

Angioplasty

        GI Tract

Sterotactic procedure

        Level I

Artherectomy

Extremities

 

        Level II

Stenting

IAC

 

        Level III

Thrombolysis

 

 

Radiology Equip

Embolization

 

 

DR CR Cassette

Pacemakers/ICDs

 

 

Arteriography:   Common carotid   Subclavian/Vertebral   Thoracic aorta   Coronary


 

      

MRI Technologist:

Nuclear Medicine:

Head

White blood scan

Neck

Planar-static

Spine

Planar-whole body

        Cervical

SPECT scanning

        Thoracic

Three-phase bone scan

        Lumbar

Brain scan

Abdomen

Thallium stress test

Pelvis

Thyroid scan

Extremities

Thyroid uptake

3-D Images

Therapeutic-thyroid

Gradient echo imaging

Bone scan

Multiplanar reconstruction

Lymphoscintigraphy

Functional MRI

Scintimammography

Spectroscopy

PET scanning

MRA

PET CT

Cardiac

Three-phase renal scan

Fluoroscopy:

Pulmonary scan (VQ)

Upper GI Series

Aerosol lungscan

Small Bowel Series

Testicular studies

Barium Enemas

Liver scan

Esophagus

Spleen scan

C-Arm Fluoroscope

Schilling’s test

Cystograms

Prostascint

Enterolysis

Osteoscan

Other:

QC – Radiopharmaceuticals

Contrast Agent Preparation

Gallium Scan

Venipuncture

Muga Scan

Management of Reaction and Extravasation

GI Bleed

Image Display

Radionuclide arteriogram

Quality Assurance

Radionuclide venogram

Equipment safety / checks

DEXA Scan

Processors safety / checks

 

MRI safety procedures

 

Radiation safety

 

Please check the type of work-related equipment you have used:
GE              Siemens              Philips              Toshiba

Other:

Please check the type of work-related computers/ PACS systems you have used:
Fuji              AGFA              Siemens              GE            

Other:

I affirm that all information given on these pages are true and accurate.             Initials                         Date
Page2 of 2


     

Please list any limitations or comments you may have on a separate sheet.

IDENTIFYING
INFORMATION

Last Name

First Name

Middle Name

Prvs Surname

LIFE SUPPORT
CERTIFICATIONS

BLS  Exp. date:

ACLS Exp. date: 

OTHER Exp. date:

EXAMS AND
REGISTRATION

A.R.D.M.S.      Other:       Registry #:       Exp. Date (mm/dd/yy)
 

RDMS       Specialty:    Abdomen     Breast      OB/GYN           Other:

RDCS       Specialty:     Adult echocardiography                Pediatric echocardiography

RVT          Specialty:     Vascular Technology              

ROUB     Specialty:     Registered ophthalmic ultrasound biometrist          

POPULATIONS

Adult

Pediatric

Neonatal

CLINICAL
EXPERIENCE

 Please check the areas below where you have clinical experience within the past 24 months and where you are currently proficient.

General:

General (continued)

Neonatal head

Transrectal procedures

Doppler studies

Neurosonology

        Carotid

Segmental pressures

        Venous (arm/leg)

 

        Arterial (arm/leg)

OB/GYN examinations

        Arterial graft

1st Trimester

        Renal

Screening

        Transcranial

Transvaginal

Thyroid

 

Breast

Ultrasound Assisted Procedures:

Cardiac

Biopsy

Aorta

Aspiration

Abdomen

Drainage

Gall bladder

Hysterosonography

Biliary Tree

Amniocentesis

Liver

Please list any additional skills or procedures you have performed:

Spleen

Pancreas

Renal

Bladder

Pelvis

Testicular

EQUIPMENT

Please check the type of work-related equipment you have used:
GE         Siemens         Toshiba         Philips         HP         Other:

COMPUTER
SYSTEMS

Please check the type of work-related computer systems / PACS you have used:
Fuji         AGFA        Siemens         GE         Other:

I affirm that all information given on these pages are true and accurate.             Initials                         Date



Temp Assignment Employees Policies and Procedures

In accepting a Temporary assignment, all Lab Force employees agree to the following policies and procedures:

EMPLOYMENT
Remember that you are a LAB FORCE employee. Your introduction to our customers through the completion of your assignments are managed by your LAB FORCE Staff Coordinator.

ATTENDANCE
• Be on time for your assignment.
• 48 hours’ notice is required if you cannot complete a given assignment.
• 24 hours’ notice is required if you cannot complete a particular day’s shift.
• Notify your supervisor or department if your attendance will be interrupted or delayed.
• Notify your Staff Coordinator at LAB FORCE if your attendance will be interrupted or delayed.
• Failure to follow these directives may jeopardize the continuation of your assignment.

HIPAA AND JCAHO STANDARDS
All Lab Force Services Temporary Assignment Employees will render care in accordance with the ethical and professional standards, policies and procedures, all applicable statutes and regulations, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the requirements of the Joint Commission on Accreditation of Health Care Organizations (“JCAHO”) and other regulatory agencies to which our customers are subject.

All Lab Force Services Temporary Assignment Employees will respect the confidential nature of all PHI (Personal Health Information) relating to patients. Including the time that said information is in the control of LFS employee and shall exercise reasonable and appropriate care that the security, integrity and confidentiality of the information is not breeched. In no circumstances is a LFS employee authorized to remove any medical record from a customer site. Further, Lab Force Employees shall comply with all applicable laws, rules, and regulations governing confidentiality, use and disclosure requirements of the federal, State and local laws and regulations, including but not limited to those provisions concerning HIV/AIDS-related information of AIDS and Immunodeficiency Virus and HIPAA.

All Lab Force Services Temporary Assignment Employees warrant that they have not been excluded from participation in federal health care programs.

UNLAWFUL HARASSMENT
It is LAB Force’s intention to maintain a work environment free from all forms of discrimination and harassment, including sexual harassment. If you believe you have been subjected to harassment you should contact LAB FORCE SERVICES central offices immediately. All complaints will be investigated and treated with the utmost confidentiality. Violations of this policy by LAB FORCE SERVICES employees will result in discipline up to and including discharge.

DRUG AND ALCOHOL ABUSE
It is the policy of LAB FORCE SERVICES that the use, possession, transfer or sale of illegal drugs or controlled substances by Temporary Assignment Employees is prohibited. Consequences may include disciplinary actions, up to and including termination. Alcohol and drug testing may include pre-employment, upon reasonable suspicion, for cause, post accident, randomly, periodically or at the request of the customer.

CONFIDENTIALITY
As a LAB FORCE employee on “Temporary” assignment to our Customers, you will be exposed to both technical and non-technical information; business methods and practices; pricing, medical records and other such information not generally available to the public. All LAB FORCE SERVICES Temporary Assignment Employees agree to keep secure and confidential any proprietary (technical and non-technical) information either during or subsequent to employment.
I understand the above policies and procedures, and accept them as a condition of my employment by Lab Force Services.
First Name  Last Name 

    I agree  

    Date

 

PO Box 4180
Windham, NH 03087-4180
Phone: 800-522-TECH
Fax: 603-893-5361

BACKGROUND CHECK

In accordance with the contract, which LAB FORCE SERVICES/NURSEPARTNERS maintains with certain customers, it is policy that various Temporary Assignment Employees must be subjected to Criminal convictions, motor vehicle, Medicare/Medicaid fraud and other reports. Lab Force Services may be requesting information from various Federal, State and other agencies which maintain records concerning your past activities.
Information such as date of birth and driver’s license number are used strictly as identifiers to insure accurate information. In no way will this information affect eligibility status for employment.
In connection with an application for employment, the undersigned hereby agrees that LAB FORCE SERVICES will be permitted to disclose my name, social security number, date of birth, race and sex to a third party firm permitting them to conduct a Record Check. In addition, Lab Force may be required to provide a copy of these reports to the facility where the temporary assignment is located.

Full Name:(First, Middle Last)

Former Name:                                     Date of Name Change:

Place of Birth                         Date of Birth:                                                                      

Sex:                          Height                        Weight                        Eye Color

             Social Security #:                                                        Race:

Driver’s License Number:               State:                     Expiration Date:

PLEASE PROVIDE ADDRESS FOR THE PAST SEVEN (7) YEARS.

Current Address: city state zip

Dates at this address: County of Residence:

 

Previous Address: city state zip

Dates at this address: County of Residence:

 

Previous Address: city state zip

Dates at this address: County of Residence:

 

Previous Address: city state zip

Dates at this address: County of Residence:

 

Previous Address: city state zip

Dates at this address: County of Residence:

 

                                      
I agree                                      Date                              

Fax completed information to LAB FORCE SERVICES Central Offices at
603-893-5361


Hepatitis B Form


Name:

SSN#

DOB:

First

Last


I have received the Hepatitis B Vaccine and have as stated on the record of my Physical Exam and affirmed by my physician or employee health service.

 

I am currently immune as stated on the record of my Physical Exam and affirmed by my physician or employee health service.

 

I refuse to receive the Hepatitis B Vaccine for the following Reason:

 


I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I understand that by declining the vaccine, I continue to be at risk of acquiring Hepatitis B and release Lab Force, Inc., (DBA NURSEPARTNERS) from any liability associated with this risk.

I have not received the Hepatitis B vaccine because:

 

 

I will be vaccinated on: (Approximate date you plan to be inoculated.)





I agree                  

Date

www.labforceservices.com

LABFORCE SERVICES
1-800-522-8324
PO Box 4180, Windham, NH 03087-4180
Fax: 603-893-5361



HEALTH, SAFETY AND COMPLIANCE QUESTIONNAIRE

Your safety on the job is important to LABFORCE. By answering the following questions you will enable us to offer you assignments, which you will be able to perform safely!

LABFORCE is an equal employment opportunity employer and complies with all handicap and disability discrimination laws.

1. Have you ever had an injury, suffered from or been treated for a condition involving:

Back/Neck/Shoulder       Hand/Wrist/Finger       Headache/Eye Strain       Other Condition       None

  a. Check if the injury involved:

Sprain      Bone Fracture      Bruise   Cut      Carpal Tunnel Syndrome/ Tendonitis

  b. Will any of the above checked injuries or conditions interfere with your ability to safely perform any of the job activities shown in the Physical
       Activities section below?

                       Explain:
                                               

  c. Would performance of any of the job activities listed in the physical activities section below be likely to aggravate a pre-existing health or medical
      condition?

                       Explain:
                                               

 2. Have you ever received worker’s compensation benefits for any of the above injuries?

                       Year:              State:

3. Do you need an accommodation (covered under the Americans with Disability Act) to successfully do the work for which you have qualified?

                       Explain:
                                               

4. Are you currently taking any medication which may cause drowsiness, slow reflexes / reactions or affect your ability to work safely?

                       Explain:
                                               

PHYSICAL ACTIVITIES SECTION: Check all activities affected by any injury or condition indicated above.
Repeated Act: Lifting/Moving     Bending/Stooping     Stretching/Reaching     Standing/Walking     Hand/Wrist Motion
Operation of: Machine/Equipment     Motor Vehicle     Video Display Terminal
Performing: Close Inspection or Detail work

I certify that LABFORCE offered me employment and conditioned the offer on LABFORCE ability to safely assign me based on the information I have provided. I further certify that the above information I have provided is complete and accurate. I agree to promptly notify LABFORCE if any of the information above changes.
VERIFIED BY LABFORCE REP:                                               DATE:

COMPLIANCE: Have you ever been convicted of a felony or misdemeanor in the USA?  
By signing below, I also agree to be tested for alcohol, illegal drugs, or other potentially intoxicating substances prior to an assignment, and/or if I am involved in an incident resulting in an injury to me or anyone else while on assignment for LABFORCE. I further authorize LABFORCE to check my worker’s compensation history and conduct a credential, drug and criminal background investigation as required.

  I agree

  Date

 

  

FIRST NAME

LAST NAME

 

 

IN CASE OF EMERGENCY PLEASE CONTACT:

 

RELATIONSHIP:

PHONE:

 

  


www.labforceservices.com
LABFORCE SERVICES
1-800-522-8324
PO Box 4180, Windham, NH 03087-4180
Fax: 603-893-5361