New Candidate Survey (Provincial Travel Nurse Team)

Staff are to complete the below survey as the initial step in their onboarding with the Provincial Travel Nurse Team.

PTNT New Candidate Survey

"*" indicates required fields

Step 1 of 3

33%

Name

This field is for validation purposes and should be left unchanged.

Please indicate your First and Last name*

First Last

Previous Surname(s)?*

Email*

Please provide your personal email address.

Contact number*

Please provide the best personal contact number to reach you at.

Is this a cellular or landline?*

cellular

landline

MANAGER REFERENCES

Please provide two (2) references. One (1) reference must be current. Staff are to ensure that the individuals listed are aware that they will be contacted prior to form submission. Individuals identified will be contacted within 48 hours of submission. If you work with an agency- staff are required to provide references from sites that you actively support. Agency owners will not be accepted as a reference.

Manager name 1*

First Last

Manager facility 1*

Manager email 1*

Manager phone 1*

Manager name 2*

First Last

Manager facility 2*

Manager email 2*

Manager phone 2*

Your address*

Please provide your full mailing address.

Street Address City Province Postal Code

Professional Designation*

Please select your professional designation.

LPN

RPN

Current Employment*

Unit

Facility

Employee ID #

Position

User ID

Work Email

Please indicate all units and facilities in which you hold an active position.

To enter more than one current employer above, please use the to the right of the row of fields.

AGENCY INFORMATION

Are you currently employed by agency?*

Yes

Agency support*

Please list all sites in which you have worked a minimum of 4 shifts / month as an agency nurse within the last 6 months.

Facility

Unit

To add more agency facilities above, please use the to the right of the row of fields.

EXPERIENCE & EDUCATION

Clinical experience*

What program(s) do you have current experience in that meet the 1+ years or 2015 hour equivalency requirement. Please note that your current skillset will be leveraged and referenced to the applicable program requirements outlined in the posting.

You may choose a maximum of four (4) programs.

Addictions

Chemotherapy – Clinic Nurse

Chemotherapy – Treatment Room

Diagnostic Imaging

Hemodialysis

Peritoneal Dialysis

Emergency – General Population

Emergency – Children’s

Endoscopy

Home Care

Critical Care – Adults

Critical Care – Neonatal

Labor and Delivery

Long Term Care

Medicine – Acute

Medicine – Transitional Care Units, Subacute

Mental Health

Obstetrics

Operating Room

Outpatient Clinic

Palliative

Pediatrics

Post Anesthesia Care Unit

Public Health – Community Care

Rehab

Special Care Unit (provides care to critically ill ventilated patients)

Step Down Unit

Surgery

Other

Other clinical experience*

Please indicate what continuing education certificate(s) / module(s) you have previously completed.*

*must be Healthcare Provider training

(you must make a selection for each certificate, please include even if expired)

	Active	Expired	Not Applicable
Advanced Cardiovascular Life Support (ACLS)
Acute Care of At Risk Newborns (ACoRN)
Basic Life Support (BLS)*
Continuous Renal Replacement Therapy (CRRT)
Canadian Triage Acuity Scale (CTAS)
ECG Rhythms, Cardiac Rhythms, Telemetry
Emergency Nursing Course – ENO Level 1
Emergency Nursing Course – ENO Level 2
Emergency Nursing Course – ENO Level 3 (resus)
Emergency Nursing Course – ENO Level 4 (triage)
Essentials of Critical Care Course (for PACU nurses) (ECCO)
WRHA Emergency Orientation Level 1a – Non Monitored
WRHA Emergency Orientation Level 1b – Monitored
WRHA Emergency Resuscitation Orientation
WRHA Emergency Orientation – Triage
Emergency Nursing Pediatric Course (ENPC)
EPICC Foundations
EPICC Trauma
Fetal Health Surveillance (FHS)
Manitoba Nephrology Nursing Course (MNNC)
Neonatal Resuscitation Program (NRP)
Obstetrical Triage Acuity Scale (OTAS)
Pediatric Advanced Life Support (PALS)
Point of Care Testing incl. istat, strep, hemocue (POCT)
Perioperative Training Program or equivalent (Periop 101) (AORN)
Procedural Sedation and Analgesia – Conscious Sedation Training
Trauma Nursing Core Course (TNCC)
Wound Care Level II – Adult Pressure Injuries
Wound Care Level II – Arterial, Venous, Mixed Lower Leg Ulcers
Wound Care Level II – Diabetic Foot Ulcers
WCCNEP / CCNOP: Critical Care Course

Additional training / skills / experience?*

Please identify any additional training / skills / experience not outlined in the above questions.

Certification Submission

Please upload all completed certifications as identified above, regardless of expiration date. Staff with upcoming sessions of required education are requested to upload the confirmation of booking as an interim placeholder.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, gif, Max. file size: 1 MB, Max. files: 10.

If you have more than 10 certificates to send, please email them to [email protected].

Please indicate what clinical access platform(s) you have access to / experience with.*

	Yes	No
ARIA – CCMB Program
eChart
EDIS – General
EDIS – Triage
EPR – Basic
EPR – Order Entry
Learning Management System (LMS)
Multifactor Authenticator App (MFA)
Occulys
Papercut (printing system in SH-SS / NHA)
Pyxis
RL6
Shift Link (existing active acct. with current employer)
Triaging (paper format)

LMS username(s)*

Please provide all username(s) that you have completed modules under. Staff will be required to access an account on an ongoing basis while employed with our program. As such please indicate if you have accessed the(se) accounts within the last 90 days.

Username

Accessed last 90 days? (Y/N)

To request more than one item above, please use the to the right of the row of fields.

Disclaimer*

By submitting this form, I affirm that all information provided is truthful, accurate and comply with the employer’s code of conduct.

I affirm