Registration: CPR Inc. Shiftboard

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It might take a few hours or days until your registration has been processed.


* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Personal Information
Maiden Name (If applicable):
Business Name:
NPI#
Social Security Number
Medicare Number
Medicare State
Medicare Number
Medicare State
Medicaid Number
Medicaid State
Medicaid Number
Medicaid State

Date of Birth:
City Born In:
State Born In:
Place of Birth - Country
Professional Designation:
* Best Way To Contact You?
Home Phone
Cell Phone
Email
Snail Mail
* Best Time to Contact You?
Morning
Afternoon
Evening
Emergency Contact Information
Emergency Contact Name
Emergency Phone Number
Emergency Contact Relationship

Credentials
Please use the box below to list states where you're currently licensed: (On Each Line List - State, License #, Expiration Date)
Do you have your own malpractice insurance?:
 Yes  No
Name of Insurance Company
Policy Number
Hospital Based Coverage
 Yes  No
Stand Alone Coverage
 Yes  No
Office Based Coverage
 Yes  No
Type of Policy:
Coverage Limits:
Claim Limit ($)
Retroactive Date
Effective Date
Expiration Date
Previous Claims
 Yes  No
If YES, Please Explain (including dates):
Drivers Licence Number
Drivers License State
Drivers Licence Expiration
Last PPD Date
PPD Positive or Negative?
ACLS Certification Expiration Date
BCLS Certification Expiration Date
NRP Certification Expiration Date
PALS Certification Expiration Date
DEA License Number
DEA License Expiration Date
AANA Certification Number
AANA Certification Expiration Date
Please list specialties / fellowships (On Each Line List - Specialty/Fellowship, Number of Years)
Describe yourself and include your strengths, experience, skills and personal qualities that would be attractive to a facility:
Do you have experience with Electronic Medical Records?:
 Yes  No
If yes, what systems?

Education
Undergraduate College:
Date Completed:
Degree:
School Attendance Start Date:
School Attendance End Date:

Undergraduate College:
Date Completed:
Degree:
School Attendance Start Date
School Attendance End Date
Nursing School:
Date Completed:
Degree:
School Attendance Start Date:
School Attendance End Date:

Graduate/Anesthesia School:
Degree:
Date Completed:
School Attendance End Date:
School Attendance Start Date:

Professional Experience
Facility Name:
Position Held:
City:
State:
Is this a teaching facility?
 Yes  No
# of Beds on Unit
Speciality
Start Date
End Date
Reason for Leaving & Additional Notes
Facility Name:
Position Held:
City:
State:
Is this a teaching facility?
 Yes  No
# of Beds on Unit
Speciality
Start Date
End Date
Reason for Leaving & Additional Notes

Clinical Skills Checklist
Clinical Areas
Ambulatory Anesthesia
Cardiac Anesthesia
ENT
Dental
General
Neuro
OB
GYN
Orthopedics
Pain Management
Pediatrics
Vascular
Reginal Anesthesia
Epidural
Caudal
Brachial Plexus Blocks
Femoral Blocks
Inter-Scalene Blocks
Local Field Blocks
Bier Blocks
Spinal
Retro-Blbar and peri-Bulbar Blocks
IV & Inhalation
Barbituates
Psychoactive Drugs
Narcotics
Volatile Anesthetics
Muscle Relaxants
Mask
Endo-tracheal Oral/Nasal
Artificial Ventillation
Specials
Arterial Lines
CVP Lines
Complex Pediatrics
Double Lumen Tube
Acute and Post Op Pain Management
Epidural Steroid Injection
Spinal Administration of Narcotics
Epidural Administration of Narcotics
Epidural Analgesic w/ Local Anesthetic
Continuous Interscalene Anesthesia

Professional References
Group / Facility
Address:
Reference Name:
Title of Reference:
Reference Phone #
Department:
Clinical Specialty:
First Reference - From Date
First Reference - To Date
Group / Facility
Address:
Reference Name:
Title of Reference:
Reference Phone #
Department:
Clinical Specialty:
Second Reference - From Date
Second Reference - To Date

Additional
Availability
Please indicate your initial available dates, shifts, etc. Once your information is loaded in our system you will be asked to complete your availability calendar.
Release, Authorization and Acknowledgement
* Please open and read the attachment. I agree, and today's date is:
Refer to:
* By checking Yes below and entering today's date you are stating that the above information given is accurate and can be used in finding placement opportunities.
 Yes  No



We appreciate your time and interest


 
 
Aurora, Colorado 80014
(866) 773-4252 x22
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