Recruiter Questionaire

Travel Company Name. __________________________________________________________

Address _________________________________________________________________________

Phone Number _______________________________ Fax _________________________________

Website ________________________________________________________________________

Recruiters Name _________________________________________________________________

Recruiters Email _________________________________________________________________

Recruiters Direct phone number______________________________________________________

Recruiters Cellular Number_________________________________________________________

Recruiters Home Telephone Number___________________________________________________

Best way to contact Recruiter ________________________ Time zone company in ______________

Time zone for Recruiter__________________ Name of Housing Manager ____________________

Other company contact names______________________________________________________

Where is the assignment we are talking about, Name of Facility_______________________________

Where is this Hospital Located_______________________________________________________

Type of Assignment_________________________________ What is the start date_____________

How long is the assignments? 4, 8, 13 weeks?__________________________________________

Does this hospital usually let nurses extend their contracts__________________________________

Are your Companies assignments country wide? ___________If not, which states do you offer employment in?

_________________________________________________________________________________

Referral Bonus ?______________________ Hospital Referral Bonus? ________________________

Travel Reimbursement? Per mile ___________________ Maximum__________________________

Can I fly to the assignment?_______ Do you pay for the Ticket upfront?________________________

Do you provide a rental car? _______________________ Allowance? ________________________

Do you provide health insurance? ________ Is it free? __________ Cost per month_____________

Monthly premium with spouse/children added _________________When does it start?___________

Insurance Co __________________________________ Group Number______________________

Type of Health Insurance: PPO _________________ HMO ______________Other ____________

Deductible ____________________ MD Co-Pay ________________ Pharmacy Co-Pay___________

Lifetime Max ____________ Pre-existing condition _________________________________ ______

Dental  _________________________ Life Insurance________________ Amt_________________

Malpractice Insurance Coverage __________________

Do you pay weekly ______________ Biweekly ____________ Direct deposit _________________

When does your current payroll period end_________  What date will you pay___________________

401K ____________ Match __________________________ Vested_________________________

How many hours per week is the assignment?  ____________ Are these guaranteed? ____________

Do you pay time and a half for CA assignments after 8 hours? _______________________________

Do you provide double OT? __________If so when does it kick in?__________________________

Cancellation Policy _______________________________ Float Policy _______________________

Is there an end of assignment bonus? __________________________________________

Any other bonuses? ________________________________________________________________

Do you have a Tax Advantage Plan? How does it work?_{__________________________________________}

 _______________________________________________________________________________

_______________________________________________________________________________

Do you provide free private housing? _______________ Shared ____________ Furnished? ________

Pets__________________ Deposits___________________ Amount refundable_________________

Amount of Housing Stipend if I don't need the apartment_____________________________________

What Furniture? ___________________________________________________________________

________________________________________________________________________________

Are Dishes, pots and pans, Linens etc supplied? ___________________________________________

Appliances provided? ______________________________________________________________

How many days can I move in before assignment  starts? ___________________________________-

Are utilities paid? _________ If yes, which utilities _______________________________________

Do you provide reimbursement for CEU's? ______________________________________________

Do you provide License reimbursement? _______________________________________________

What tests if any do I have to take  ______________________________________________________

Special License _________________________ What Certifications do I need______________________

Documents completed and returned to agency or filled out online:: Application form___ Resume___ 

Skills Checklists___ Licenses____ ACLS____ BCLS____ PALS ____ TNCC ____ MICN ____ Others_____

Physical _______ MMR Titres_______ TB Test result______  or X ray report______ 

How many References Needed_____ Who I have given for references____________________________

 _________________________________________________________________________________

_________________________________________________________________________________

Any special company comments________________________________________________________

. _______________________________________________________________________________

_________________________________________________________________________________

Better Business Bureau Results? ______________________________________________________

Other company nurses at this facility with phone or email contact info_____________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Name of person that referred me to this Agency__________________________________________