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FAQ
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Apply for Anesthesia Services
CRNA APPLICATION
CERTIFIED REGISTERED NURSE ANESTHETIST APPLICATION
POSITION
CHECK ONE
LOCUM TENENS
PERMANENT
Date
Month
Day
Year
Incorporated Name
State Incorporated In
Date Incorporated
Federal Tax ID #
SECTION I
PERSONAL INFORMATION
NAME
Soc. Sec. #
Birth Place
Date
MM slash DD slash YYYY
Height
Weight (LBS)
SEX
MALE
FEMALE
Present Address
City
State / Province / Region
ZIP / Postal Code
Telephone
Residence
Telephone
Work
Telephone
Fax
Telephone
Cell
Email
Marital Status
Spouse's Name
Number of Children
Children's Ages
Citizenship
Date
If Naturalized
MM slash DD slash YYYY
IN CASE OF EMERGENCY, CONTACT #1:
TELEPHONE NUMBER
Relationship
IN CASE OF EMERGENCY, CONTACT #2:
TELEPHONE NUMBER
Relationship
Hobbies
Geographic Preference
Present Salary
Desired Salary
HOW DO YOU KNOW WHEN YOU HAVE DONE A GOOD JOB?
SECTION II: LOCUM TENENS
(Please Answer Each Blank)
1. Do you consider free-lancing as an interim position or a career?
2. What size hospital do you wish to work in?
Less than 100
100 to 300 beds
Over 300 beds
Trauma Hospital
3. How many weeks per year do you plan to travel?
4. Who travels with you?
Spouse
Family
Special Friend
Pet
DESCRIBE
5. Going to locum assignments, do you:
FLY
DRIVE
Do you have frequent flyer number?
SECTION III: EDUCATION
Anesthesia Training
(FROM / TO) INSTITUTION, CITY, STATE
DEGREE
MS
YES
NO
Nurses Training
(FROM / TO) INSTITUTION, CITY, STATE
DEGREE
College
(FROM / TO) INSTITUTION, CITY, STATE
DEGREE
High School
(FROM / TO) INSTITUTION, CITY, STATE
DEGREE
SECTION IV: EXPERIENCE
Please give employment history starting with present position
Please use month/year
(FROM / TO) HOSPITAL NAME & CITY/TELEPHONE
POSITION/ Reason for Leaving
Please use month/year
(FROM / TO) HOSPITAL NAME & CITY/TELEPHONE
POSITION/ Reason for Leaving
Please use month/year
(FROM / TO) HOSPITAL NAME & CITY/TELEPHONE
POSITION/ Reason for Leaving
If Presently Employed, May we call your Employer?
WHAT ARE YOUR PROFESSIONAL OBJECTIVES?
Have you ever been in the military?
YES
NO
Dates
From ______ to _______ Branch
Discharge
Are you now a member of the Active Reserve?
Branch & Location
SECTION V: LICENSING
What is your original state of licensure?
What states do you have active license(s)?
AANA Certification #
Expiration Date
BCLS?
Expiration:
ACLS?
Expiration:
PALS?
Expiration:
Professional Liability
Policy No.
Professional Liability
Limits of Liability
Professional Liability
Professional Liability:
Have you ever been the defendant in a malpractice suit?
YES
NO
To your knowledge, is there a malpractice claim pending?
YES
NO
If yes, please give a brief explanation
Have you ever had a state license revoked or suspended?
YES
NO
If yes, please give a brief explanation
Have you ever been treated for drugs, alcohol, or nerves?
YES
NO
If yes, please give a brief explanation
SECTION VI: REFERENCES
Please give names, addresses and telephone numbers of 4 professional references. This reference should be able to verify your clinical skills and ability in Anesthesia. Please only list references that have worked with you within the past 24 months. References must be physicians either Anesthesiologists or Surgeons along with 1 Peer.
1. Name
Title
Facility/Group
Dept
Address
Telephone
Position
2. Name
Title
Facility/Group
Dept
Address
Telephone
Position
3. Name
Title
Facility/Group
Dept
Address
Telephone
Position
4. Name
Title
Facility/Group
Dept:
Address
Telephone
Position
SECTION VII: CREDENTIALS
IT IS NECESSARY FOR THIS SECTION TO BE COMPLETED. MANY HOSPITALS HAVE CERTAIN REQUIREMENTS. WITH THIS ON FILE, WE CAN SAVE EVERYONE TIME AND BEST SERVE YOU IF WE KNOW WHERE YOUR SPECIALTIES LIE.
I. GENERAL ANESTHESIA - a. Balanced
(PROFICIENT)
COMMENTS
I. GENERAL ANESTHESIA - b. Inhalation
(PROFICIENT)
COMMENTS
I. GENERAL ANESTHESIA - c. Neurolept
(PROFICIENT)
COMMENTS
I. GENERAL ANESTHESIA - d. Dissassociative
(PROFICIENT)
COMMENTS
II. REGIONAL ANESTHESIA - a. Epidural
(PROFICIENT)
COMMENTS
II. REGIONAL ANESTHESIA - b. Subarachnoid
(PROFICIENT)
COMMENTS
II. REGIONAL ANESTHESIA - c. Axillary
(PROFICIENT)
COMMENTS
II. REGIONAL ANESTHESIA - d. Bier
(PROFICIENT)
COMMENTS
II. REGIONAL ANESTHESIA - e. Other
(PROFICIENT)
COMMENTS
III. PEDIATRIC GENERAL ANESTHESIA - a. Newborn
(PROFICIENT)
COMMENTS
III. PEDIATRIC GENERAL ANESTHESIA - b. Infant - 6 years
(PROFICIENT)
COMMENTS
III. PEDIATRIC GENERAL ANESTHESIA - c. Tubes & Tonsils only
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - a. Open heart
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - b. Thoracic
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - c. Major vascular
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - d. OB
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - e. Neurosurgical
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - f. Multiple Trauma
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - g. Outpatient Surgery
(PROFICIENT)
COMMENTS
IV. SPECIALIZATION - h. Emergency Surgery
(PROFICIENT)
COMMENTS
V. INVASIVE & NON-INVASIVE MONITORS - a. A line
(PROFICIENT)
MONITORING ONLY
V. INVASIVE & NON-INVASIVE MONITORS - b. CVP line
(PROFICIENT)
MONITORING ONLY
V. INVASIVE & NON-INVASIVE MONITORS - c. Swan Ganz
(PROFICIENT)
MONITORING ONLY
V. INVASIVE & NON-INVASIVE MONITORS - d. Cardiac output
(PROFICIENT)
MONITORING ONLY
V. INVASIVE & NON-INVASIVE MONITORS - e. Mass Spec.
(PROFICIENT)
MONITORING ONLY
V. INVASIVE & NON-INVASIVE MONITORS - f. Pulse Oximetry
(PROFICIENT)
MONITORING ONLY
V. INVASIVE & NON-INVASIVE MONITORS - g. Capnography
(PROFICIENT)
MONITORING ONLY
ADDITIONAL COMMENTS
NAME (PRINTED)
Signature
Date
MM slash DD slash YYYY
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