Please Provide Following Information

  • Drivers License*
  • Social Security Card*
  • CPR Card*
  • Current TB*
  • Hepatitis B titers if applicable
  • ACLS, PALS, NALS if applicable
  • Certification if applicable
  • Total combined Image content size should not be grater than 2 MB.
    Please enter a valid file type. [.pdf, .docx, .doc, .jpeg, .jpg].

Contact Information

Work and Education Information

  Yes   No
  Yes   No
  Yes   No

Hepatitis B Vaccine


Please read options carefully before selecting your answer.

  1. HIPAA regulations protect an individual's right to the privacy of his/her medical information, that is, to keep it from falling into the hands of people who would use it for commercial advantage, personal gain or malicious harm.
  2. Any healthcare providers, health plans or clearinghouses that electronically transmit medical Information such as billing, claims, enrollment or eligibility verification must meet HIPAA regulations.
  3. HIPAA regulations apply to medical information that contains any of a number of patient identifiers including name, social security number, telephone number, medical record number or zip code.
  4. Covered entities cannot get around HIPAA by using other associates to handle their electronic transactions. Covered entities must ensure that their associates have security measures in place and technology sufficient to avoid accidental disclosure of an individuals PHI.
  5. A covered entity's specific efforts to protect the integrity of the health information it holds and prevent unauthorized breaches of privacy.

Age specific Competency

Southern Medical Staffing, LLC
Independent Contractor Agreement
Registered Nurse

This agreement dated this day of , 20 , is executed by and between Southern Medical Staffing, LLC ("SMS", located at 1500 Metro Dr., Alexandria, Louisiana 71301, and ("Contractor"), whose mailing address is .

Whereas, SMS seeks to engage Contractor to accomplish the objectives described in the Exhibit titled "Qualifications and Description of Services to be Performed by a Registered Nurse", which is attached hereto.

Whereas, based on the nature of the relationship that the parties intend to establish, SMS hereby engages Contractor as an Independent Contractor.

Now, therefore, in consideration of the mutual promises and covenants of the parties as herein contained, the parties hereto agree and contract as follows:

  1. SMS hereby engages Contractors to accomplish the objectives described in the Exhibit titled "Qualifications and Description of Services to be performed by a Registered Nurse", which is attached hereto, which can be amended from time to time in accordance with Paragraph 12.
  2. SMS enters into this agreement based on Contractor's demonstrated ability to accomplish the objectives described in the Exhibit attached hereto. Consequently, SMS will not provide Contractor with any training or instructions with respect to the services to be provided hereunder. Contractor declares that he/she has complied with all federal, state, and local business permit and licensing requirements necessary to conduct business. Contractor declares that he/she obtains his/her own worker's compensation policy. Contractor will hold harmless and indemnify SMS for any and all claims arising out of injury, disability, or death of Contractor. Contractor understands that the insurance contract and other information that he/she provides to SMS may be disclosed to any Facility desiring to utilize his/her professional nursing services. Contractor understands that SMs shall not obtain or pay for any insurance on behalf of Contractor.
  3. This agreement is not to be interpreted or construed as creating or establishing an employee/employer relationship between Contractor and SMS. Consistent with the parties' intent that the relationship created by this Agreement be that of service recipient and Independent Contractor, Contractor shall retain the exclusive right to control and direct all details of the services that Contractor performs hereunder, including, where, when and how the services are to be performed and is free from any control or direction of SMS. Contractor's failure to accomplish an objective described in the attached Exhibit shall constitute a material breach of this Agreement.
  4. Contractor shall not be eligible to participate in any benefit programs that SMS now or hereafter maintains for its employees and, in the event Contractor for any reason were to become eligible to participate in a SMS sponsored benefit program, Contractor hereby waives any such right to participate in the program. This waiver of any right to participate in SMS sponsored employee benefit programs represents a material component of the terms of compensation agreed to by these parties and is not in any way conditioned on any representation of assumption concerning statues of Contractor with respect to SMS as an employer of Independent Contractor.
  5. For all purposes, including but not limited to the Federal Insurance Contributions Act (FICA), the Social Security Act, the Federal Unemployment Act (FUTA), income tax withholding and any and all other federal, state, and local laws, rules and regulations, Contractor shall be treated as an Independent Contractor and not as an employee with respect to SMS. Contractor is therefore responsible for filing and paying his/her own payroll taxes (Internal Revenue Service and State of Louisiana) and agree to hold harmless SMS for any failure to comply with any taxing authority. At the request of SMS, Contractor also agrees to supply proof of filing and payment. Contractor also agrees to fully indemnify SMS for any and all taxes, fees, costs, and penalties assessed by any taxing authority of any type whatsoever that should seek to collect from SMS on behalf of Contractor.
  6. Contractor acknowledges and agrees that Contractor shall be responsible (as a self-employed individual) for filing all tax returns, tax declarations and tax scheduled, and for payment of all taxes required, when due, with respect to any and all compensation earned by Contractor under this Agreement. SMS will neither pay nor withhold any employment taxes with respect to the compensation it pays Contractor. Rather, SMS will report the amounts it pays to Contractor on Internal Revenue Service Form 1099, to the extent required to do so under applicable Internal Revenue Code provisions.
  7. SMS shall have no obligation to pay a Contractor's fee for services provided prior to receipt of a completed and signed time slip/invoice requesting payment. SMs will not reimburse Contractor for any expenses, including but not limited to fees, fines, licenses, or taxes, incurred in connection with the performance of services hereunder unless otherwise agreed by SMS in accordance with Paragraph 12.
  8. Monies paid to Contractor are not considered wages and will be paid at a negotiated rate to be determined on a case by case basis. Fees for Contractor's services are directly billed to Facilities by SMS and if any negotiated rate differs from that originally determined then Contractor may not directly bill any Facility.
  9. Contractor provides services to SMS on a part time basis and reserves the right to, and intends to perform services for other staffing agencies/companies.
  10. Neither party hereto may terminate this Agreement unless the party first provides the other party with written notice. In the case of a material breach of this Agreement by one party, however, the other party shall have the right to terminate this Agreement immediately by providing the breaching party with a notice of termination. The termination shall be effective at the time the notice is received by the breaching party.
  11. This Agreement shall be governed by the construed and enforced in accordance with the laws of the State of Louisiana. Any and all disputes arising out of, or relating to the performance of services contracted for, under this Agreement, shall be settled by arbitration. Such arbitration shall be final and binding upon the parties, and shall be the sole and exclusive remedy of the parties with respect to any dispute arising out of, relating to, or resulting from the interpretation of the terms of this Agreement, or any breach thereof. The costs of such arbitrations shall be borne equally by the parties. This Paragraph 11 shall survive the termination of this Agreement.
  12. This Agreement shall constitute the entire written agreement between the parties, and shall supersede any and all agreements or understanding in effect between the parties hereto. Neither this Agreement nor attached Exhibit may be modified except by written agreement executed by the parties hereto.
  13. If any provision of this Agreement is found, held or deemed to be void, unlawful or unenforceable under any applicable statute or other controlling law, the remainder of this Agreement shall continue in full force and effect.
  14. No breach of any provision hereof can be waived unless in writing. Waiver of any breach of any provision hereof shall not be deemed to be waiver of any breach of the same, of any other provision.
  15. Any notice required or permitted under this Agreement shall be in writing and sent to the other party by first class mail at the address set forth above, or to such other address as a party hereto may specify in writing.

Qualifications and Description of Services to
be performed by a Registered Nurse


  1. Holds and maintains a current license from the Louisiana State Board of Nursing.
  2. Current CPR Certification
  3. One year of experience
  4. Current TB skin test
  5. Negative drug screen
  6. Negative background check


  1. Accepts responsibilities delegated by the head nurse or team leader and evaluates the nursing care provided in the area assigned.
  2. Provides leadership in the interpretation and application of the philosophy and objective of nursing service in assigned areas.
  3. As a team leader, directs the abilities and skills of staff assigned to his/her jurisdiction and makes nurses notes according to audit committee standards.
  4. Assists the physician with procedures and treatments. Administers treatments including sterile procedures.
  5. Participates in team conferences with team leaders and makes up team assignments.
  6. Guides personnel in evaluating patient needs.
  7. Performs patient care within the principles of Team Nursing, reporting pertinent observations or complaints to the team leader and/or head nurse.
  8. Assists head nurse or charge nurse in personnel work evaluation
  9. Administers medications according to hospital policy.
  10. Practices economical use of equipment and supplies, informs proper authority of discrepancies.
  11. Attends and supports Inservice Education Programs
  12. Participates in or initiates CPR and Codes when necessary.
  13. Serves on nursing committee when requested
  14. Makes out patient assignment sheets when delegated by the head nurse.

Med/Surg Skills Checklist

1 = No Experience

2 = Some experience but require supervision or additional training

3 = Experienced and does not require supervision or additional training

Pelease Select experience level as it applies to you.

1. Cardiac*

Cardiac Arrest/CPR
Interpretation of Arrhythmias

Care of Patient With*

Open Sternal Wound Debridement
Post MI
Pre/Post Cardiac Cath
Pre/Post Cardiac Surgery

Use and Administration of the Following*

Preparation of Emergency Drugs
Thrombolytic Agents

2. Gastrointestinal*

NG Tube Insertion
Gastrostomy Tube
Jejunostomy Tube
Enterostomal Care

Care of Patient With*

Bowel obstruction
Esophageal Bleeding
G.I. Bleed
Liver Transplant
Paralytic Ileus
Whipple Procedure

3. Genitourinary/Renal*

Electrolyte Imbalance/Replacement
Foley Catheter Insertion
GU Irrigations
Nephrostomy Tube
Suprapubic Tube

Care of Patient With*

Chronic/Acute Renal Failure
Renal Transplant
Renal Trauma
Shunts and Fistulas

4. Neurology*

Assessment of Neuro Signs
Assist With Lumbar Puncture
Glascow Coma Scale
Halo Traction
Seizure Precautions

Care of Patient With*

Cranial Hemorrhage
Head Injury/Trauma
Multiple Sclerosis
Neuro Injury/Trauma
Post-op AV-Shunt
Seizure Activity

Use and Administration of the Following*

Magnesium Sulfate

5. Orthopedics*

Total Joint Replacement
Arthroscopic Surgery
Bucks Extension
K-Wires/Steinman Pins
Removal of Hardware
Spika Cast/Body Cast
Cast Removal
Skeletal Traction
Ortho Trauma

Care of Patient With*

Delerium Tremens
HIV infection

6. Respiratory*

Ambuing Techniques
Chest Tubes (Emerson/Pleuravac)
Establishing an Airway
Incentive Spirometer
Interpretation of ABGs
Nasotracheal Suctioning
Oral Suctioning
Pulse Oximetry
Use of IPPB

Care of Patient With*

Inhalation Injuries
Pre/Post Thoracic Surgery
Pulmonary Edema
Pulmonary Embolism

Use and Administration of the Following:*

Breathing Treatments

7. Vascular*

Administration of Blood & Blood Products
Air Occlusive Dressing
Fluid Overload
Heparin Drips
Hickman/Broviac/Groshong Catheters
Infusion Pumps
Knowledge of Normal Serum Lab Values
Maintenance of Heparin Look
Peripheral Pulses
Peritoneal Dialysis
Sickle Cell Anemia
Starting IV's
Central Lines
PICC lines
Ultrasonic Doppler

8. Other*

Isolation Techniques
Diabetic Teaching
Burn Patients

RN/LPN Job Description

Communication Skills

  1. Report is given and received in a professional manner.
  2. Communication with physicians and other healthcare team members remains professional and appropriate.
  3. Demonstrates respect for others at all times.
  4. Helps maintain a work environment free of violence, hostility, or harassment of any kind.
  5. Demonstrates a positive attitude. Any complaints or problems are presented professionally through the chain of command.

Job Function/Knowledge/Productivity

  1. Demonstrates knowledge of responsibilities and expectations.
  2. Demonstrates organizational skills, and perform duties in a timely manner.
  3. Demonstrates knowledge and appropriate action in unexpected or emergent situations.
  4. Takes initiative in performing duties, mastering new skills, and helping co-workers when the needs arise.

Facility Policies

  1. Wears name badge while on duty.
  2. Ensures that job duties, doctor's orders, and charting are complete at the end of shift.
  3. Reviews and adheres to the policies and procedures of the facility.
  4. Adheres to timesheet policy with accurate documentation on the timesheet, verified by a supervisor.
  5. Maintains strict adherence to HIPAA regulations.
  6. Demonstrates respect for the patients and families, always being a patient advocate and respecting their rights.
  7. Patient education is provided and documented
  8. Locates emergency equipment in area (crash cart, fire extingquisher, etc.).

Patient Care

  1. Demonstrates clinical expertise and professionalism while 
    caring for the patient.
  2. Accepts and performs duties that are within competency level.
  3. Asks questions appropriately when unsure of a task or interpretation( doctor's order, lab values, etc.).
  4. Duties are performed in a timely manner.
  5. Accepts duties that are within age-specific competency.
  6. Reports observations, complaints and patient needs to the charge nurse or supervisor.
  7. Attends any in-services or updates required by facility.
  8. Utilizes equipment provided by the facility to ensure safe administration of medication.
  9. Reports for duty on time, gives a 2-hour notice If unable to report for duty, and at least a 30-minute notice if running late.
This field is required