| PERSONAL INFORMATION |
| First Name: |
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| Last Name: |
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| Business Name: |
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| Address2: (Apt, Unit, Suite) |
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Zip:
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| City Born In: |
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State Born In:
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| Home Phone: |
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| Cell Phone: |
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| Email Address: |
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| NPI# |
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| Date of Birth: |
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| Maiden Name (If applicable): |
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| Best Way To Contact You?: |
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Best Time to Contact You?: |
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| Professional Designation: |
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| Availability: |
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| Choice of Travel Destination: |
City/State Region |
Proximity: City / # of Miles / Statewide |
| 1st Choice |
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Within:
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| 2nd Choice |
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Within:
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| 3rd Choice |
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Within:
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| INSURANCE, LICENSING & CERTIFICATIONS |
| Please use the box below to list states where you're currently licensed: (On Each Line List - State, License #, Expiration Date) |
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| Do you have your own malpractice insurance?:
YES
NO |
| If Yes: |
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| Coverage Limits: |
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| Hospital Based?:
YES
NO |
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| Stand-Alone?:
YES
NO |
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| Previous Claims:
YES
NO |
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| If YES, Please Explain (Including Dates): |
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| Please list your current certifications and include their expirpation dates: |
| ACLS:
YES
NO |
Expiration Date:
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| BCLS:
YES
NO |
Expiration Date:
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| NRP:
YES
NO |
Expiration Date:
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| PALS:
YES
NO |
Expiration Date:
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| Recertification:
YES
NO |
Expiration Date:
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| Please list specialties / fellowships (On Each Line List - Specialty/Fellowship, Number of Years) |
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| Describe yourself and include your strengths, experience, skills and personal qualities that would be attractive to a facility: |
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| Do you have experience with Electronic Medical Records?:
YES
NO |
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| If yes, please describe below: |
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| EDUCATION & PROFESSIONAL EXPERIENCE |
| EDUCATIONAL EXPERIENCE |
| Undergraduate College: |
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Date Completed:
Degree:
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| Undergraduate College: |
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Date Completed:
Degree:
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| Nursing School: |
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Date Completed:
Degree:
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| Anesthesia School: |
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Date Completed:
Degree:
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| PROFESSIONAL EXPERIENCE- (List most recent employer first.) |
| Facility Name: |
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State:
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| Position Held: |
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This a teaching facility |
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Shift:
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| Dates Employed: |
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| # of Beds on Unit: |
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| Reason for Leaving: |
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| Additional Information: |
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| Facility Name: |
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| City: |
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State:
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| Position Held: |
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This a teaching facility |
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| Dates Employed: |
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| # of Beds on Unit: |
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| Reason for Leaving: |
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| Facility Name: |
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| City: |
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State:
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| Position Held: |
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This a teaching facility |
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Shift:
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| Dates Employed: |
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| # of Beds on Unit: |
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| Reason for Leaving: |
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| Facility Name: |
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State:
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| Position Held: |
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This a teaching facility |
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| Dates Employed: |
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| CLINICAL SKILLS CHECKLIST |
| CLINICAL AREAS |
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Ambulatory Anesthesia |
General |
Orthopedics |
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Cardiac Anesthesia |
Neuro |
Pain Management |
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ENT |
OB |
Pediatrics |
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Dental |
GYN |
Vascular |
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| REGIONAL ANESTHESIA |
IV & INHALATION |
SPECIALS |
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Epidural |
Barbituates |
Arterial Lines |
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Caudal |
Psychoactive Drugs |
CVP Lines |
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Brachial Plexus Blocks |
Narcotics |
Complex Pediatrics |
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Femoral Blocks |
Volatile Anesthetics |
Double Lumen Tube |
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Inter-Scalene Blocks |
Muscle Relaxants |
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Local Field Blocks |
Mask |
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Bier Blocks |
Endo-tracheal Oral/Nasal |
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Spinal |
Artificial Ventilation |
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Retro-Bulbar and Peri- Bulbar Blocks |
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| ACUTE and POST OP PAIN MANAGEMENT |
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Epidural Steroid Injection |
Epidural Analgesic w/ Local Anesthetic |
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Spinal Administration of Narcotics |
Continuous Interscalene Anesthesia |
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Epidural Administration of Narcotics |
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| PROFESSIONAL REFERENCES |
| Reference #1 |
| Company / Facility: |
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| Name of Reference: |
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| Title of Reference: |
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| Clinical Specialty: |
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| Reference #2 |
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| Reference #3 |
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| Reference #4 |
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| Clinical Specialty: |
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| RELEASE, AUTHORIZATION AND ACKNOWLEDGMENT |
In regards to my application to CPR, Inc.:
- I certify that the above information I have provided on this application and attachments is true and accurate, that it can be used by CPR, Inc. for evaluating my potential as n anesthesia provider, and that CPR, Inc. can rely on the truthfulness of my application.
- I acknowledge in making medical application for membership to the medical staff, I authorize CPR, Inc. and its representatives, to obtain any information that may be relevant to an evaluation of my professional qualifications, including references, information about disciplinary actions or other credentials or confidential information.
- I hereby release CPR, Inc. , its officers, employees, and representatives, and third parties which provide or receive information regarding my credentials. Further, I agree to indemnify, defend and hold CPR, Inc., its officers, employees, and representatives and third parties harmless from any and all claims, causes of action, damages, judgments and expenses, including reasonable attorney’s fees, arising from or related to the collection, verification and dissemination of my credentialing information.
- I understand that I have the burden of providing accurate information to CPR, Inc. to demonstrate my qualifications. I understand that any misrepresentation on this application may constitute grounds for denial or referral to practice assignments.
- I understand that I am responsible for notifying CPR, Inc. of any changes affecting my professional status. I certify that the information contained in this application is accurate and complete.
- I acknowledge that I am not an employee of CPR, Inc. and that any services that I provide to a CPR, Inc. client will be provided as an independent contractor.
- I agree that if I am referred by CPR, Inc. to any opportunity, I will promptly notify CPR, Inc. each time I provide locum tenens or full time services to the CPR, Inc. client, within two years of the performance of any covered locum tenens services.
By checking the box below and entering today's date you are stating that the above
information given is accurate and can be used in finding placement opportunities. |
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I agree to the above information. Today's Date:
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