Attachment E - Nurse Checklist.xlsx

XLSX spreadsheet 15 KB Posted

Attached to
Non-Personal Service Contract for Quality Management-Risk Manager position at the Gallup Indian Medical Center
Solicitation number
75H71021Q00054
Issued by

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File Type Posted
Attachment B - Statement of Duties_Risk Management Nurse.pdf PDF
75H71021Q00054.pdf PDF
Attachment A - Performance Work Statement.pdf PDF
Attachment C - Wage Determination.pdf PDF
Attachment D - Pricing Schedule.pdf PDF

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Sheet1

CONTRACT NURSE PROFILE CHECKLIST
RN NAME: __________________________________________RN Current Phone Number: _____________________________
UNIT APPLYING FOR: __________________________________RN Email Address: ____________________________________
COMPANY: __________________________________________
COMPANY POC & PH #: ________________________________Nurse Availability Date: _________________________________
___________________________________________________
ADMINISTRATIVE DOCUMENTS:Date Rec'd:Attached:Comments:
Current/Updated resume
Finger Print Cards
Two (2) Forms of ID (Driver License, SSN, Passport)
OF-306-Declaration of Federal Employment (revised Oct 2011)
OF-306 Child Care Addendum form (Exp. Date 11/30/18)
OIG Clearance
RN Active License
RN Inactive License
References
Skills Checklist
H-1B Form I-129 (required if non-US citizen)
Copy of VISA with expiration date (required if non-US citizen)
Copy of SSN w/Social Security Administration Verification for Authenticity (required if non-US citizen)
CERTIFICATIONS DOCUMENTS (based on Specialty)
BCLS (Mandatory) Expire Date:
ACLS
TNCC Or Advance Trauma Care Nurse or Trauma Nurse Spec.
PALS
WCON
NRP
Fetal Monitoring Course Certificate
IMMUNIZATION & PHYSICAL DOCUMENTS:
PE (within the Year)
PPD
Chest X-Ray (if PPD positive)
MMR #1 vaccine (required if born after 1956)
MMR #2 vaccine (required if born after 1956)
MMR Titer (required if no vaccines)
Hepatitis B Series #1 (required if no Titer)
Hepatitis B Series #2 (required if no Titer)
Hepatitis B Series #3 (required if no Titer)
Hepatitis B Titer (required if no Titer)
Varicella Vaccine (required if no Titer)
Varicella Titer (required if no vaccines
TDAP Vaccine
Flu vaccine within the year
revised 2/10/16 gc

Sheet2

Sheet3

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