Licenses and Certifications
* Do you hold any professional licenses of certifications?
Please list all the professional licenses and certifications you hold:: | |
* Have you ever had any actions taken against you or had any warnings, disciplinary actions, or other limitations placed upon your license, by any state board?
* Have you ever been, or are you currently excluded, debarred, or suspended from participation in any Federal or State healthcare programs or in Federal procurement or non-procurement programs?
Please use the space below for additional information in correlation with any of the above three questions:
* Please select all of the skills with which you have had experience working:
Location Applying For
Please state the location you are applying for: (City, Zip Code)
COVID-19 Screening
* Have you traveled outside of the United States in the last 14 days?
If Yes, please state the location: | |
* Have you had contact with anyone who has tested positive for COVID-19 in the last 14 days?
* Have you experienced any of the following symptoms in the last 14 days?
* Fever greater than 100.4
* Cough
* Shortness of breath or difficulty breathing
* Consistent fatigue
* Muscle or body aches
* New loss of taste or smell
* Congestion or runny nose
* Diarrhea
* Are you currently experiencing a temperature over 100 degrees Fahrenheit, difficulty breathing or coughing?
If you have answered Yes to any of the first two questions , please contact your primary care provider or your State Department of Health for further directions.
California Department of Health - COVID-19 Information Line:
1-833-4CA4ALL (1-833-422-4255)
If you have answered No to the first two questions but Yes to any of the remaining questions, please contact your healthcare provider.
Please DO NOT visit a medical facility unless your symptoms are severe or if you are severely ill. Meanwhile, do not get close to anyone with a compromised immune system or other underlying health conditions.
* Have you received both doses of your COVID-19 Vaccine?
If you have received two doses of your COVID-19 Vaccine, have you also received your booster shot?
Authorization
I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.