dear applicant, - therightsolutions.com · dear applicant, thank you for your inquiry! ... facts on...

1/10/2008 Dear Applicant, Thank you for your inquiry! Enclosed is the application you requested. I have travel assignments all across the country, just waiting for you! Here are just a few of the reasons our Healthcare Professionals continue to travel with TRS:

The Right Solutions has agreements with over 1,400 facilities nationwide, and receives forty to sixty new travel assignments every day!

Individual Retirement Account (IRA)!

Great Pay with Optimal Tax Savings!

FREE License Reimbursement!

Hassle-Free Housing Arrangements!

Maximum allowable tax-free travel allowances!

24-hour support!

$500 referral bonus, and $1000 if you refer a friend while you are on assignment with us!

Free First Day Health, Life and Dental Insurance with Prescription Coverage

You're insured by the best group plan on every assignment, with high quality medical, preventative diagnostic and basic dental coverage, health screening benefit, routine well child, critical illness rider, and accidental death and life insurance, on the first day of all 8-week or greater staffing assignments. It's portable, so you can take your insurance with you if you decide to leave.

The Right Solutions is the most innovative travel company in the industry. I am constantly looking for new ways to get you more money. For instance, in most cases over half the money you receive can be TAX FREE! Call to find out more. Please review the enclosed travel packet. By completing and returning the packet, you will join the elite team of travel professionals who have experienced the excitement, adventure, and rewards of traveling with The Right Solutions. Please fax or mail your application materials today. Do not hesitate to call us with any questions you might have. We are here to help. Sincerely,

P.S. For more information in regards to our benefits, please refer to http://www.therightsolutions.com/payandbenefits/?menu=pay or if I can help you in any way, please do not hesitate to call.

RETURN DOCUMENT CHECKLIST

Priority 1 These documents are required for submission to a position. Completed Personal Notes

Basic Information Sheet Employment HistoryMinimum 3 References Candidate Placement Agreement Skills Checklists (Required lists: (M/S or Basic) plus Specialties willing to work)

Priority 2 The documents below are required before you can go on assignment. I-9 (Employment Eligibility Verification – Complete Section 1 & Sign and Date)

TRS Policies (Drug Free , Safety, and Workers Comp)

HIPPA Confidentiality Physician's Statement Hep B/Tetanus Declination IV Certification [LPNs Only]

Referral Bonuses [Optional]

Med Surg / Medication Administration Questionnaire

Provide Clear and Current Copies of all below itemsSocial Security card (front)Drivers License (front)

All Professional Licenses and Certifications (front)CPR card (front, back & signed)ACLS, NALS, PALS, AND/OR NRP cards [if available] (front & back)(Proof of Hepatitis Series or Titer) OR Hepatitis Declination Proof of Negative TB within the last 12 Months, OR X-Ray [if TB is positive – less than 5 years old] (front)Rubella Titer OR Proof of 2 Immunizations (front)Rubeola Titer OR Proof of 2 Immunizations (front)Varicella Titer (front)

RETURN COMPLETED DOCUMENTS BY FAX TO 1-866-270-1609 OR BY MAIL TO: THE RIGHT SOLUTIONS

P.O. BOX 595 TONTITOWN, AR 72770

NOTE: The more quickly we receive your information the faster we will be able to place you at exciting travel destinations, so send us your information as soon as possible.

Start having fun and earning great money!

BASIC INFORMATION SHEET

Full Name:____________________________________

List all other names you ever have been known by (includes maiden & previuos marriage names) Date Available to Travel (mm/dd/yyyy) Best time of day to reach you Social Security Number (xxx-xx-xxxx) BirthDate (mm/dd/yyyy) E-mail Address

Phone # (xxx-xxx-xxxx) Mobile # (xxx-xxx-xxxx) Other # (xxx-xxx-xxxx) Drivers License # Expire Date (mm /dd/yyyy)

Permanent Address City State Zip

Emergency Contact Name Relationship Contact Address Emg. Contact Daytime # Emg. Contact Evening #

U.S. Citizen Yes No If no, legal right to work in the U.S.? Yes No Military Service Yes No If yes, Start Date (mm/dd/yyyy): End Date (mm/dd/yyyy) :

Have you ever been convicted of a misdemeanor or felony? If yes, attach separate sheet with explanation. Yes No Have you ever been named as a defendant in a professional liability action? Yes No Has your professional license or certification ever been investigated or suspended?

If yes, attach separate sheet with explanation. Yes No

Education and Current Certifications: Classification: (include copies of certification) RN Other:

School Location Graduation Date (mm/dd/yyyy)

Degree or Certification

College Graduate School Other School

Certification (Other List)

Expiration Date (mm/dd/yyyy)





ACLS IV PTA CCCs NRP RPT COTA OTR SLP CPR PALS Trauma Core

Licensure (include photocopies of all licenses held and list additional licenses on separate sheet if necessary):

State License Number Is License Temporary

Expiration Date (mm/dd/yyyy) State License Number

Is License Temporary


Yes Yes Yes Yes Yes Yes

The information provided herein for participation with The Right Solutions is true, correct and complete. I acknowledge that any misstatement or omission of facts on the resume will result in the termination of my relationship with The Right Solutions. I authorize The Right Solutions to release this information and reference information to The Right Solutions’ Client Facilities. I understand that by giving The Right Solutions permission to submit my information for assignment opportunities, I am also agreeing to any criminal background search and pre-employment drug screening that may be required by certain states or Client Facilities. I authorize The Right Solutions to investigate all information contained herein and secure any information from all my employers, references, and academic institutions and to release this information to any Client Facility where I may be considered for a travel work assignment. I have received the Health Care Professional handbook and agree to abide by the policies. The Right Solutions is an equal opportunity employer.

Signature Date (mm/dd/yyyy)

EMPLOYMENT HISTORY Full Name:____________________________

Please list any gap(s) (and their reasons) in your employment history greater than 60 days that has occurred in the last 3 years. Example for listing gap(s) on the lines below: 6/14/2005-8/29/2005 due to Vacation; 11/10/2005-3/4/2006 due to Remodel Home; 2006-7/1/2006 due to Illness Please List your gap(s) here:

Are you employed now? Yes No , If so may we contact your present employer? Yes No Please indicate all of your employment, beginning with your most recent employer:

Facility Name / Employer Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy) # of Beds (if Facility)

Employer Address City State Zip

Supervisor Name/Title Supervisor Phone Reason for leaving

Discipline (RN, LPN, PT, etc…) / Title Specialty (M/S, ER – Level III, ICU, Tele, OR, Psych Adult, etc…) / Other Experience

Please check one only: Travel Assignment Per Diem Assignment Core Staff Assignment NON-Medical
















EMPLOYMENT HISTORY CONTINUEDFull Name:____________________________





















EMPLOYMENT VERIFICATION & PROFESSIONAL REFERENCE FORM

Full Name:_________________________

Please Complete and Fax to: 866-270-1609

Name used while working at this Facility/Employer Social Security Number (xxx-xx-xxxx)

Facility Name / Personal Reference Name Fax Number (xxx-xxx-xxxx) Phone (xxx-xxx-xxxx)

Address City State Zip

Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy) Supervisor Name – Title/Co-Worker @ Facility Name

Discipline (RN, LPN, PT, etc…) / Title Specialty (M/S, ER – Level III, ICU, Tele, OR, Psych Adult, etc…) /Other Experience

Please check one only: Core Staff Assignment Travel Assignment Per Diem Assignment NON-Medical

I, ____________________________________________, give my permission to the above-named facility to release information regarding my employment while at that facility to The Right Solutions. (All references will be checked.)

***************** APPLICANT DOES NOT WRITE BELOW THIS LINE*******************

The person above has registered with The Right Solutions and has listed you as a previous employer. We would appreciate your assistance in verifying that the above employment information is correct and evaluating their job performance. All information is confidential.

Is this applicant eligible for rehire? Yes No If not, please explain:

Reason for leaving:

Personal Evaluation Excellent Above Average Proficient Below Average Poor Quality of work Quantity of work Attitude Adaptability to work situations Dependability Cooperation Ability to get along with others Attendance and punctuality Professional appearance

Facility confirms dates of employment only due to policy: Yes No

Comments:

Name/Title Department Date (mm/dd/yyyy) TRS Verified by Phone Signature Date (mm/dd/yyyy) Please respond to this message immediately, since employment verification cannot be completed without your

assistance. This individual is being credentialed according to the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) who require reference verification.

CANDIDATE PLACEMENT AGREEMENT

Full Name:______________________________

This Agreement is made by and between AmediStaf, LLC., d.b.a. The Right Solutions Medical Staffing, located at 311 Henri De Tonti, Tontitown, Arkansas 72770 (here in after referred to as "Company" or "we" or "us" or "our") and _FullName______________________, located at ADDR , CITY , STATE , ZIP (hereinafter referred to as "Health Care Professional” or “HCP" or "you" or "your").

WHEREAS Company is a Delaware Corporation engaged in the business of recruiting and supplying temporary medical personnel within the health care field in the United States of America; and HCP seeks to become a “Candidate” as described in this agreement.

Definitions

Candidate: A Registered Nurse, Licensed Practical/Vocational Nurse, Physician Assistant, Certified Registered Nurse Anesthetist, Nurse Practitioners, Surgical Technician, Physical Therapist, Physical Therapy Assistant, Occupational Therapist, Certified Occupational Therapy Assistant, Speech & Language Pathologist, Respiratory Therapist, Laboratory Technician, Electroneurodiagnostic Technician, or Imaging Technician who successfully completes all pre-employment testing and signs this agreement; thereby agreeing to comply with all the terms and conditions therein, who also maintains and provides to Company proof of all the necessary credentials required by State and Federal Law and Company to be considered qualified to work in one or more of these disciplines. The HCP ceases to be a Candidate at any time that any such credentials expire, are revoked or for any reason are deemed to be invalid, or proof of the current validity of such credentials is not supplied by HCP to Company.

HCP Agreement: A document issued by Company detailing all the arrangements and details pertaining to each Travel Assignment, such as Pay Rate, Travel Destination, Housing Arrangements, Travel Method, etc. Each HCP Agreement becomes valid and binding when verbally offered by Company and verbally accepted by you. This will occur after you have completed sign-up and are offered a position by a Recruiter. Each valid and binding HCP Agreement is attached hereto and becomes a part of this agreement by reference.

Recruiter: A dedicated specialist assigned to you to personally assist you with all aspects of each travel assignment.

Client: A contracted customer of Company, typically a hospital, where you may be assigned to work.

HCP: You become an HCP at the time you begin your first shift. The HCP ceases to have a relationship with Company at any time that any such credentials expire, are revoked or for any reason, are deemed to be invalid, or proof of the current validity of such credentials is not supplied by HCP to Company. The HCP’s engagement ceases if there is a failure on the HCP’s part to comply with any and all testing requirements of Company or Client.

TERMS AND CONDITIONS Placement You agree and understand that Company is NOT a placement firm. You understand that once you become an HCP of Company, Company will incur certain costs,

including but not limited to insurance, recruiting, bonuses, housing and incentive pay. You agree that you will not seek nor accept employment either directly or indirectly in any capacity from any Client at which an assignment is proposed or accepted, beginning on the date of proposal/acceptance, until a period of 90 days has elapsed from the final day worked of your last assignment for the Company. You agree and understand that you will pay to Company a fee of ten thousand dollars ($10,000.00) which will become immediately due and payable if you accept employment either directly or indirectly in any capacity from any Client at which an assignment is proposed or accepted until the period of 90 days has elapsed from the final day worked of your last assignment worked for Company. You agree that this fee may be deducted from any paycheck, travel, housing, licensing and/or bonus money due to you from Company. You agree and understand that it is your responsibility, before accepting any employment from any potential employer, to determine whether such potential employer is a Client, as defined in this Agreement. You agree and understand that after Company submits your profile to a Client, or after you are notified by Company that you are being considered for or offered a particular work assignment, and for a period of 90 days thereafter, that you will not accept a work assignment or employment of any kind at that facility, directly or indirectly, from such Client(s), or from any other agency or entity. HCP understands that any contracts offered for employment will be honored to the fullest extent possible. HCP understands that certain circumstances may require renegotiation of some contracts, even after it has been fully executed by both parties. These circumstances may include acts of God, changes of bill rate with Client, default of contract by HCP or Client, and any other unforeseen act or event which may jeopardize financial solvency of Company. HCP understands that a full disclosure of any changes to contract made under this clause will be delivered to HCP via certified mail within 30 days. By signing this Agreement, you acknowledge that you freely and voluntarily consent to such payroll deductions.

Cancellation of Assignment If you cancel a scheduled work assignment prematurely, walk off the job, or Client cancels based on your failure to meet the screening, credentialing or performance

requirements, you will be responsible for costs incurred by Company in scheduling the assignment. By signing this Agreement and initialing this page, you acknowledge that you consent to deduct from your wages costs, fees, and expenses incurred by Company as a result of your failure to abide by the terms of this Agreement. Deductions include but are not limited to Bonus and travel advances; Damages to property as a result of your negligence, including pet damages; Fees and expenses incurred by Company to obtain state licenses; Unused airline tickets; Housing costs including security deposits, hotel stays, travel reimbursement, and local transportation; Any other actual costs that are otherwise unrecoverable. Should an assignment be shortened or canceled for any reason, all monies due to you at the end of the assignment will be paid within forty-five (45) days of completion and upon Company receiving the proper receipts, written documentation, and in accordance with State and Federal law.

Facility Cancellations It is your responsibility to immediately notify your Recruiter of any absenteeism or when Client cancels a shift or reduces your hours. You are responsible for notifying

Company at 888-987-8233 immediately upon receiving notice of cancellation, and before leaving Client’s facility.

Please initial here (Initials or Signature Required): Page 1 of 2

Scheduling You agree to work the hours required by Client and acknowledge that Client will be responsible for all scheduling. Client controls the schedule and work assignments.

Client has the right, where necessary, to require you to float from your assigned unit to another unit for which you are qualified or to another Client facility within the Client’s healthcare system when applicable. Client will make every effort to schedule you to work the schedule agreed upon. Should you desire to change the schedule agreed upon, you must make a written request to Client no less than seven days prior to such change. You must submit the written request to Client and Company. However, Client shall have the final decision regarding changes to your schedule.

Standards of Service As a highly qualified and highly compensated Candidate, you will be responsible for all of your decisions and actions while on assignments.

You agree to provide Company with ongoing information concerning the status of each work assignment as well as any problems or difficulties encountered. This would include any issues with the assignment, housing, travel, or pay. Excessive tardiness, absentees, call-ins, poor attitude, insubordination, general uncooperativeness, failure to comply with Client and Company policies, procedures, rules and regulations may be sufficient to cause a breach of this Agreement on your part.

While on assignment, you agree to observe relevant standards for your occupational specialty, the medical staff by-laws, schedules, rules of Clients, any State or Federal requirements that apply to you, as well as policies of Company. You will maintain appropriate records, which remain the property of Client. Records and other Client property including but not limited to patient logs, facility manuals, etc., shall remain on the premise of the Client. It is a Company requirement that you complete all necessary chart documentation prior to leaving each shift. You agree to abide by HIPAA.

You agree to keep us fully advised of any disciplinary or quality assurance proceedings involving you (e.g., flags by licensing boards, quality assurance committees, hospitals, professional societies, Medicare or Medicaid, and malpractice claims or lawsuits). You agree to promptly notify us in the event any such proceedings are pending or are instituted, whether or not they are related to work performed through Company. By signing this Agreement, you are also representing to us that no such actions are pending and you have not been previously sanctioned except as specifically indicated in writing and attached hereto.

If you become aware of an act or omission by you or by others that relates to your assignments through Company that could result in legal liability, you must notify us immediately in order to protect both your and our interests. Early knowledge and evaluation of possible claims will often protect you from nuisance suits, and you agree to provide us with written incident reports as requested by our Customer Service/Risk Management Team or corporate Counsel. Your failure to advise us of such incident(s) may increase your personal liability and adversely affect insurance coverage.

Period of Agreement This Agreement is effective for one year beginning on the date of signatory below and will automatically renew for an additional one year on each anniversary date. You

or we may terminate this Agreement at any time upon 30-day written notice of intent to terminate to the other. In the event of termination of this Agreement, all provisions of this Agreement will remain in full force and effect until both Company and HCP have completed and fulfilled all their respective obligations under this Agreement and any attachments to this Agreement.

Electronic Disclaimer; Privacy Statement and Confidentiality During the course of our relationship, you will gain information, data, items and materials relating to Company, Clients, personnel, business plans, methods and

techniques, financing, financial condition, customers, lists, accounts, pricing, debts, assets, facilities and marketing, which you agree is Confidential Information owned by Company. Company will gain information, data and materials about your education, work history, licenses, income and working relationships, which Company agrees is confidential information owned by you. Company and you agree during the term of this Agreement and for two years after its termination not to disclose to third parties or use for benefit or gain the Confidential Information of the other party, unless disclosure is required by law or with written consent. All documents and data received from you, or on your behalf, become the property of Company and will not be returned, except for original licenses.

You understand that if you violate this Agreement, Company will be entitled to recover reasonable attorney’s fees and costs in addition to other appropriate remedies including injunctive relief, specific performance and/or damages.

You represent and warrant to us that your execution of this Agreement and the performance of any assignment hereunder will not violate any other contract or agreement by which you are bound.

You will not compete with our interests or the interests of any Clients while on assignment.

The laws of the State of Arkansas shall govern this agreement. If any provision of this Agreement is held to be invalid or unenforceable, such provision shall be struck and the remaining provisions shall be enforced. Failure to act by Company with respect to a breach by Client or others does not waive Company's right to act with respect to subsequent or similar breaches. This Agreement sets forth the entire understanding and agreement between us with respect to the subject matter hereof. IN WITNESS WHEREOF, each of the parties has executed this Agreement, in the case of the Company by its duly authorized Representative; as of the day and year first above written. My signature below establishes I understand documents or contracts may not be invalidated solely because they are in electronic form or were executed with an electronic signature, under the 2001 Electronic Signatures in Global and National commerce Act (See www.access.gpo.gov/nara/nara005.html ). I understand I hold a password which maintains my identity. See Privacy Policy at www.therightsolutions.com .

Certification of Taxpayer Identification Number (Social Security Number)

By your signature below and under penalties of perjury, you certify that the number shown on this form is your correct Social Security Number/Taxpayer Identification Number.

Social Security Number (xxx-xx-xxxx)

Signature Date (mm/dd/yyyy) The Right Solutions Signature Date (mm/dd/yyyy) Page 2 of 2

Please Call 1-888-987-8233 Or Fax 1-866-270-1609If You Have Any Questions Or Need Further Information

Basic Skills Checklist

1 of 3Directions: Fill in the appropriate bubble or checkbox corresponding to each question.

1 - No Experience 2 - Minimum Experience 3 - Experienced 4 - Proficient

1 of 3www.therightsolutions.comBasic Skills Checklist

Continued On Next Page

Work w/a multidisciplinary team to plan care/discharge

Write nursing notes using the focused-note approach

Use a care pathway

Use a goal directed care plan

Care Plan Formulation Experience

Assessing patients according to age-specific changes

Assessing and describing levels of consciousness

Using appropriate interview techniques

Assessing for fall risk

Assessing skin breakdown potential

Assessing pupillary response as part of neuro assessment

Auscultation & Identification of bowel sounds

Auscultation & Identification of heart & lung sounds

Using an oto-ophthalmoscope to evaluate retina, eardrum

Identification of abnormal heart & lung sounds

Patient Assessment Skills Experience

Do heparin flushes

Add medications to IV solutions

Assess for and manage complications, adverse reactions

Convert IV lines to heparin locks

Use IV pumps and PCA pumps

Assist w/central line insertion, DC central lines

Hang blood products and monitor blood infusions

Start IVs w/butterfly, cannula and safety IV needles

Care for the patient with an acute allergic reaction

Calculate IV drug drip rates for cardiac medications

Give chemotherapy medications

Prepare primary and secondary IV bags and tubings

Collaborate w/pharmacy lab on measuring drug levels

Modify IV administration for the latex allergy patient

Intravenous Therapy and Specialty Medications Experience

Administer medications through gastric tubes

Administer medications via button infusers & ports

Recognize adverse reactions to medications

Give IV push and piggyback medications

Administer oral and topical route medications

Administer medications via injection

Medication Administration Experience



2 of 3


Continued On Next Page

Collect anaerobic and aerobic specimens for culture

Collect 5 and 24 hour urine specimens

Conduct capillary blood sugar test

Collect urine for UA, culture and sensitivity

Collect stool for blood, ova and parasites

Specimen Collection Experience

Assist w/temporary pacemaker insertion

Able to use a portable oxygen tank

Can put a laryngoscope together, assist w/ intubation

Understands principles of cardiac rehabilitation

Care for a CABG patient pre and post op

Care for a cardiac cath patient pre and post cath

Can use a bag/valve/mask set up

Can recognize death-producing cardiac rhythms

Can apply telemetry leads for Lead II monitoring

Knows ACLS algorithms for various arrest problems

Can insert oral and nasal airways

Can use a defibrillator and/or AED

Cardiac Patient Care Experience



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JCAHO Prohibited Abbreviations

JCAHO 2006 National Safety Goals

JCAHO Experience

Monitor intracranial pressure

Set up and manage chest tubes

Do continuous bladder irrigation

Use sequential pressure devices

Use wound suction devices and machines

Manage the patient in skeletal or buck’s traction

Give colostomy care, manage appliances

Take care of a trach

Set up and direct care of the patient in isolation

Manage an epidural catheter for pain control

Insert, manage and remove foley catheters

Dressings; sterile, clean, wet-to-dry, compression, etc.

Can apply knee immobilizers and hip abductors

Can do oral and nasopharyngeal suctioning

Prepares and applies warm and cold packs

Can apply slings, bandages and binders

Assist w/thoracentesis, paracentesis, lumbar puncture

Insert, manage & remove nasogastric & feeding tubes

Use a Doppler to assess peripheral pulses

Monitor CPM machine function

Medical Surgical Patient Care Experience

DateSignature

I-9 Instructions

(Employment Eligibility Verification)

Please be aware that the US Citizenship and Immigration Service mandates that TRS keep the ORIGINAL I-9 Form on file for all employees. TRS also needs to keep the attached Agent Form on file as well. Please follow these instructions CAREFULLY to ensure that you are in compliance.

PLEASE NOTE: By law, TRS is required to have the original I-9 Form on file by the 3rd day after starting your assignment.

Instructions for Health Care Professional:

Step 1 Complete all blanks in Section 1 of the I-9 Form. Step 2 Present your original identification documents to an Agent. Step 3 The Agent will examine your documents to ensure that you have presented either: • One document from List A or • One document from List B AND one document from list C (see back of the I-9 Form for

this list

THE AGENT MUST RECORD THE DOCUMENTS IN SECTION 2 OF THE I-9 FORM AND MUST COMPLETE THE CERTIFICATION AND THE AGENT FORM.

Step 4 Attach to the I-9 Form, clear and legible copies of the document(s) you presented to the Notary Public.

Step 5 Return all pages of the original I-9 Form and copies of the document(s) in the postage-paid envelope provided.

Instructions for Agent:

Step 1 Be sure that the employee completes ALL parts of Section 1 and that the employee signs and dates the form in the appropriate place.

Step 2 If the employee makes an error in completing the form, either have her/him mark through the error and correct it. Or destroy the incorrect form and begin a new form. If the employee corrects the original form, have the employee initial and date the correction.

Step 3 Be sure that the documents that are presented are original or certified documents. Step 4 Be sure that the documents presented relate to the person sitting before the agent (i.e. the person

sitting there looks like the person in the picture).

Step 5 Be sure to complete ALL parts of Section 2. Step 6 Even though the verification documents may be attached to the completed I-9 form, information

regarding the documents must be completed in Section 2, including the issuing authority and any expiration dates.

Step 7 Be sure that the agent completes the blank for the date in the Certification and Section 2 is signed and dated.

THANK YOU for your cooperation in this very important matter!

If the I-9 Form is incomplete or the supporting documents are not received, TRS will return it to you.

*U.S. Citizenship and Immigration Services allow companies to appoint professionals as their agents to complete the I-9 Form. The Right Solutions appoints notary publics, personnel officers, attorneys, and accountants. The following is an excerpt Regarding Remote Hires from www.uscis.gov.

“It is not unusual for a U.S. employer to hire a new employee who doesn’t physically come to that employer’s offices to complete paperwork. In such cases, employers may designate agents to carry out their I-9 responsibilities. Agents may include notaries public, accountant, attorneys, personnel officers, foremen, etc. An employer should choose an agent cautiously, since it will be held responsible for the actions of that agent. Note: Employers should not carry out I-9 responsibilities by means of documents faxed by a new employee or through identifying numbers appearing on acceptable documents. The employer must review original documents. Likewise, Forms I-9 should not be mailed to a new employee to complete Section 2 himself or herself.”

Any questions? Please call your recruiter.

Faxed copies of the I-9 Form are not acceptable.

Federal law requires The Right Solutions to keep originals on file.

TRS POLICIES

Full Name:___________________________________________

SAFETY RULES/POLICY 1. The use of alcohol or drugs during business hours is strictly prohibited. 2. All Health Care Professionals (HCPs) are required to use proper body mechanics to lift patients. 3. Operate only the equipment that you have been authorized or directed by your supervisor. 4. Report all faulty equipment. Do not repair faulty equipment. 5. Report all unsafe conditions. Do not try to correct them unless authorized or directed by your supervisor. 6. Follow good hand washing techniques. 7. FOLLOW UNIVERSAL PRECAUTIONS. Wear protective equipment. 8. Follow fall precautions and bed alarm procedures. 9. Follow proper procedures to dispose of all hypodermic needles. No recapping needles. 10. Dress appropriately. Wear low-heeled shoes with rubber soles and heels.

WORKERS COMPENSATION POLICY Workers Compensation Insurance is carried on all HCPs in the event an injury should arise in the course of employment for a client. All injuries will

be reported immediately to the facility and The Right Solutions. The HCP may be subject to a penalty for late reporting. An incident report must be filed at the time of injury and submitted to The Right Solutions.

DRUG FREE WORKPLACE POLICY It is the policy of The Right Solutions that all new HCPs must have a drug test at our expense and the results kept on file with The Right Solutions. I understand that it is the policy of The Right Solutions to absolutely prohibit the use of illegal drugs and the possession, concealment, transportation,

or distribution of illegal drugs, alcohol, and other unauthorized items on company property or while on a job assignment. Being under the influence of controlled substances refers to being in an unfit condition to work whether or not impairment exists. Violation of this policy is grounds for termination of our relationship. Any termination will be referred to the State Board of Licensing or Certification according to law.

I understand that in accordance with the policy of The Right Solutions, I may be required to submit to random drug testing. This testing may be done

for pre-employment purposes, probable cause, random testing, legislated testing, and for occurrence of work-related injury or incident. Any reasonable doubt will be considered cause.

Ark. Code Ann. 11-14-106: 5. Post-accident testing. After an accident which results in an injury, the covered employer shall require the Health Care

Professional to submit to a drug or alcohol test in accordance with this rule. Post accident specimen collection for alcohol testing shall be done within eight (8) hours of the accident. Post accident specimen collection for drugs shall be done within thirty-two (32) hours of the accident.

I understand that should there be a violation of this policy I will be terminated from my relationship with The Right Solutions. I understand that

should there be a positive test I will be unqualified to work for The Right Solutions now and in the future. Should there be any question of drugs missing/counts off, or any other questionable activity this will be reported to the State Board of Nursing, the sheriff or police, or any other applicable authority.

I understand that I may be assigned to different legal jurisdictions. I acknowledge that if any conflict exists between this policy and a different legal

jurisdiction, this policy will be amended. I agree to cooperate with The Right Solutions to maintain a drug free workplace. Evidence of tampering or an adulterated sample will be considered a failure to cooperate with the drug free workplace policy.

CRIMINAL BACKGROUND RELEASE In connection with your application at The Right Solutions, a criminal background check will be requested or made on you. Failure to provide

consent will deny further consideration of your application. If the check reveals a criminal conviction, you will be informed of the record and be given a reasonable opportunity to provide clarifying information. If upon further review, it is The Right Solutions judgment that the conviction has a nexus to the position for which you have applied, the application process will terminate or, if already working with The Right Solutions, your relationship will terminate. You will be informed of such action.

Authorization: I hereby authorize without reservation, any party or agency contacted by The Right Solutions, any of its agents, or any entity

employed by The Right Solutions for such purposes to furnish the above-mentioned information. I have the right to make a request The Right Solutions or its agents, under the federal Fair Credit Reporting Act, upon proper identification and the payment of any authorized fees, for the information in its files on me at the time of my request.


HIPAA CONFIDENTIALITY AND NONDISCLOSURE AGREEMENT

Full Name:______________________________

Applies to all employees (including administration, managers, supervisors and applicable physicians); volunteers, agency, temporary and registry

personnel, students, interns, and contracted personnel.

The intent of these laws and policies is to assure that confidentiality of information is maintained while used for business and clinical operations. In

my job I may see or hear confidential information in any form (oral, written, electronic) regarding:

Patients and/or their family members (such as patient records, test results, conversations, financial information) Employees, physicians, volunteers and contractors (such as employment records, corrective action, disciplinary action)

I, , AGREE TO AND ACKNOWLEDGE THE FOLLOWING: I will protect the privacy of all business and medical information relating to our patients, members, employees and health care providers. I know that confidential information I learn on my job does not belong to me and I have no right or ownership to it. The Right Solutions and /or

facility may take away my access to confidential information at any time.

I will not misuse confidential information and will only access information necessary to do my job. I will not disclose any confidential

information unless required to do so in the official capacity of my relationship, employment or contract with The Right Solutions and/or facility.

I will not share, charge or destroy any confidential information unless it is part of my job to do so. If any of these tasks are part of my job, I will

follow the correct department procedure or the instructions of my supervisor and/or DON (such as shredding confidential paper). If a demand from an oversight agency, law enforcement or government agency is made upon me from outside The Right Solutions and or facility to disclose confidential information; I will document this by giving written notice to my supervisor and/or DON.

I will only print information from a facility and/or The Right Solutions' information system when necessary for a legitimate work related

purpose. I am accountable for this information until it is properly filed or disposed of.

If I have access to electronic equipment and/or records, I will keep my computer password secret and I will not share it with any unauthorized

individual. I am accountable for this information until it is properly filed or disposed of.

I understand that I have an obligation to report to my DON and/or Clinical Supervisor if I think someone is misusing confidential information or

is using my password. I further understand that The Right Solutions and/or facility will not tolerate any retaliation against me for making a report.

On termination of my employment, I will return to The Right Solutions and/or facility all copies of documents containing The Right Solutions'

and/or the facility's' confidential information or data in my possession or control. I will leave all facility materials and documents at the facility when I leave.

I understand that failure to comply with this agreement may result in corrective action up to, and including, termination of my relationship with

The Right Solutions and/or facility. I understand that I may also be subject to other remedies allowed by law. I understand that I will be responsible for any direct or consequential damages resulting from any violation of this Agreement. I understand that I must also comply with any laws, regulations, and The Right Solutions and/or facility policies. This agreement shall survive the termination of my official relationship, employment or contract with The Right Solutions.

I have read and understand this Confidentiality and Nondisclosure Agreement.


The Right Solutions Signature Date (mm/dd/yyyy)

Annual Physician’s Statement Instructions:

Form must be signed by MD, DO, NP, PA or CNS

Do not fill out the TB questionnaire section unless you have a positive TB

History of Varicella or MMR is not sufficient as proof for immunity. You must have dates of immunizations or titers.

If you DO NOT complete the section on the form titled “This Section Must Be Completed,” the titer or immunization must be a lab report or document signed by a MD, DO, NP, PA or CNS.

PHYSICIAN’S STATEMENT

Note: It is the responsibilities of the Traveler to have their physician fill out the appropriate section of this form.THIS SECTION MUST BE COMPLETED

Titers Date (mm/dd/yyyy)

Immunity Present

Immunity Not Present

Tuberculosis Date (mm/dd/yyyy )

Results

Hepatitis B TB Skin Test

Measles (Rubeola) (within last year) Mumps

Chest X Ray (if skin test positive)

Rubella Varicella *

The TB Questionnaire is required if a chest x-ray is completed.

[Other List]

Tuberculosis Equipment Do Have Type Size

Immunizations Date Date Date Hepa Mask Yes

(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) Hepatitis B Series Please check ‘Yes’ if the Traveler has had the condition. MMR

Yes Yes Yes Varivax Arthritis Epilepsy Seizures Mental Disorders Tetanus/Diphtheria Asthma/Bronchitis Hepatitis A Shortness of Breath [Other List] Audio Problems Hepatitis B Tuberculosis

Back/Spinal Prob. Latex Allergy Visual Problems

Color Blindness

*Note: History of Chicken Pox is not acceptable. It must be titer or immunization.

I have examined the individual named above with respect to the job duties and qualifications for the position from the job description, and based on my medical judgement, this individual can perform the essential job functions and possesses the qualifications identified on the job description and the various required titer and/or immunizations. The above identified individual’s ability to perform the job description’s essential functions/qualifications as identified on the job

description is limited by the following restrictions: By signing below, I certify that the above statement accurately reflects my medical opinion.

Said Traveler cannot perform essential functions of his/her profession due to the following reason(s):

By signing below I certify that the above information is valid.

Physician’s Signature Printed Physician’s Name Date (mm/dd/yyyy)

Tuberculosis Screening Questionnaire

If you have a chest x-ray, the Tuberculosis Questionnaire is required to be completed and signed by a doctor (NP or PA not valid). Yes No Date (mm/dd/yyyy) Yes No Date (mm/dd/yyyy)

HX of Positive TB skin test (PPD)? Hx of Allergy to TB Test HX of BCG Exposure Last Chest x-Ray

Please check ‘Yes’ if the applicant has had any of the following problems for three weeks or longer: Yes No Yes No Yes No Yes No Chronic Cough (greater than 3 weeks) Production of Sputum Fever Fatigue/Tiredness Unexplained Weight Loss Blood Streaked Sputum Night Sweats Shortness of Breath

I have examined the individual above, and to the best of my knowledge, he/she has no evidence of pulmonary tuberculosis or contagium unless I have checked the box below for evidence of pulmonary tuberculosis or contagium.

Said applicant has pulmonary tuberculosis or contagium. By signing below I certify that the above information is valid.

Physician’s Signature Printed Physician’s Name and Address Date (mm/dd/yyyy)


Hep B/Tetanus Declination

Full Name:______________________________

I, _______________________, am free from health impairment which might interfere with my duty including the habituation of alcohol or current addiction to depressants, stimulates, narcotics, or other drugs which may alter my behavior.

During my relationship with The Right Solutions and while on assignment at client facilities, I, _________________________, agree to hold

harmless both AmediStaf, LLC, d.b.a. The Right Solutions and any prospective facility at which I may be employed through them, along with any owners, directors, employees, staff, and agents of said entities, from any and all liability arising out of my refusal of any immunization and/or failure to supply proof of my vaccinations. I understand I cannot continue my relationship without proper immunization.

Tetanus Vaccination:

Have COMPLETED a Tetanus Vaccination

DECLINE the Tetanus Vaccination Hepatitis B Vaccination: This section for declining/consent for vaccination is mandatory under 29 CFR Part 1910.1030 I understand the OSHA guideline and (Please check one only): Have COMPLETED the Hepatitis B series. (If completed, documentation MUST be provided.)

DECLINE the Hepatitis B Vaccination.


LPNPROOF OF IV CAPABILITIES Full Name:_____________________________

If you do not have an IV Certification, please have a licensed RN, Nurse Practitioner, or MD witness your IV competence and have them sign below stating that they have observed your successful capabilities of the below criteria.

I, (Observer Printed Name) , have observed, , start and maintain IV Catheters, start IV’s with Butterfly Cannula and Safety IV Needles, convert an IV line to a Heparin

Lock and administer heparin flushes.

Name/Title of Observer Date (mm/dd/yyyy)

Facility Where Abilities Were Observed Facility State

TRS Verified by Phone Signature Date (mm/dd/yyyy)

REFERRAL BONUSES! Full Name: _______________________

EARN UP TO $1000.00!! Referring your friends to travel with The Right Solutions can mean great opportunities for them, and $1000.00 for you. Simply tell us about any of your Healthcare Professional friends that you think would like to hear about traveling with The Right Solutions. For each one that completes 500 hours working on a travel assignment with us, you will receive $1000.00! Recipient of referral bonus must be on contract with TRS at the time the referred nurse works 500 hours to receive $1000.00. If recipient is not on contract with TRS at the time the referred nurse completes 500 hours the bonus will be $500.00.

Simply list the names below and return the list with your paperwork. Feel free to add an additional sheet if necessary.

Referral’s Name and Occupation Phone Number Email AddressExample: Nancy T. Traveler, RN 1-888-987-8233 nancytraveler@therightsolutions

dear applicant, - therightsolutions.com · dear applicant, thank you for your inquiry! ... facts on...

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