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Time Card
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The following competencies must be completed annually in order for you to remain active with The Nurse Agency. A Quality Control Expiration notice will be sent out to you 45 days before a competency is set to expire. Our OSHA, HIPAA and Sexual Harassment trainings and Skills Checklists are administered by Relias Learning. If you did not receive an email with a link to complete these competencies, please call us and we will email them to you.
Haven't worked for us in over a year and interested in reactivating? Click here for our Employee Address/Employment Update form.
To download a form, click on the link. You must have Acrobat Reader to view these documents. You may download Acrobat Reader here.
Haven't worked for us in over a year and interested in reactivating? Click here for our Employee Address/Employment Update form.
To download a form, click on the link. You must have Acrobat Reader to view these documents. You may download Acrobat Reader here.
- Influenza Education and Vaccination Status Form
- Physician form or Physician statement
- Conflict of Interest Statement
- A TB test from the past twelve months or a Chest X-ray within five years (if you test positive for TB).
- TB Questionnaire (only complete if you test positive for TB).
- Evaluation Form
Application Materials
The following documents and licenses are required and must be on file for all employees. We will send these out to you via Adobe Sign as part of your onboarding process.
Our application may be completed by selecting the "Apply Now" button below. All other forms may be downloaded by clicking on their links. Our OSHA, HIPAA and Sexual Harassment trainings and Skills Checklists are administered by Relias Health. We will send you a link to complete these tests after you complete your area specific exam. You must have the Acrobat Reader to view most of these documents. You may download the Acrobat Reader here.
Our application may be completed by selecting the "Apply Now" button below. All other forms may be downloaded by clicking on their links. Our OSHA, HIPAA and Sexual Harassment trainings and Skills Checklists are administered by Relias Health. We will send you a link to complete these tests after you complete your area specific exam. You must have the Acrobat Reader to view most of these documents. You may download the Acrobat Reader here.
1. Application Documentation:
- Employment Verification Form (Please complete two (2) forms)
- Employment Eligibility Form (I-9 Form)
- Conflict of Interest Form
- State W-4 Form
- Federal W-4 Form
- Two Professional References (one is required to be a Charge RN or Manager who can evaluate your skills) Please give us both cell and work numbers.
- Criminal Background Check
- Influenza Education and Vaccination Status Form (annual flu vaccination is required to staff most of our clients).
- A physical or physicians statement from the past twelve months (annual requirement)
- Hepatitis B Documentation (vaccination series, titer, or signed declination)
- A TB test from the past twelve months or a recent Chest X-Ray (TB test is an annual requirement)
- TB Questionnaire - Only complete this if you test positive for TB.
- Proof of Immunity to Rubeola and Rubella and Mumps (positive titer or two MMRs within ten years)
- Positive Varicella titer
- Urine drug screen
- Respirator fit test (this is an annual requirement and can be completed in our office)
- COVID Vaccine card
- Tdap from the past 10 years
- Proof of Flu Vaccination (annual flu vaccination is required in order to staff at most hospitals).
- A current Illinois or Indiana Nursing License or MA, CNA Certification
- A current CPR/ACLS card (only American Heart Association Cards are accepted)
- NIH Stroke Scale Certificate (required for ER at Little Company of Mary Hospital )
- Proof of eligibility to work in the United States (Social Security card and State Issued ID or Passport or Birth Certificate and State Issued ID)
JCAHO Compliance
The Nurse Agency operates our business in accordance with all applicable laws, rules and regulations and the highest ethical standards of fairness, honesty and common sense. All employees are encouraged to report any perceived breach of ethics or conflict of interest. You may do so anonymously by clicking on the JCAHO Compliance Reporting link below.
All completed forms are sent via email to Penny Golden, RN, Director of Compliance. Your email is confidential and will not result in any retaliation against you.
To report any perceived infraction or impropriety made by The Nurse Agency or one of our employees, please call JCAHO's Office of Quality Monitoring at (800) 994-6610 or email: complaint@jointcommission.org
All completed forms are sent via email to Penny Golden, RN, Director of Compliance. Your email is confidential and will not result in any retaliation against you.
To report any perceived infraction or impropriety made by The Nurse Agency or one of our employees, please call JCAHO's Office of Quality Monitoring at (800) 994-6610 or email: complaint@jointcommission.org
The Nurse Agency 566 W. Adams St., Suite 550, Chicago, IL 60661
Phone: (773) 779-8200 FAX: (773) 779-8866
Email: info@thenurseagency.com
Phone: (773) 779-8200 FAX: (773) 779-8866
Email: info@thenurseagency.com