EA-Applicant Form
Please complete the following short questionnaire. Once completed an Excel Representative will contact you.
Email address *
CONTACT INFORMATION
Name *
Your answer
Address:
Your answer
DATE OF BIRTH *
MM
/
DD
/
YYYY
E-Mail address
Your answer
How would you prefer us to contact you? *
Required
POSITION SEEKING
State of Residency *
The state you have chosen as your residential state for licensure and tax purposes
Your answer
Experience/Licensure/Disciplinary Actions
Number of years experience as a CRNA *
If less than 2 years- you must have experience working without medical direction
Your answer
Phone Number
Your answer
Previous employment summary and reason for wanting to change your place of work.. *
Your answer
Check all states below in which you are currently licensed *
Required
Have you had any license, certification, registration, or permit revoked, suspended, denied, placed on probation, voluntarily surrendered, or otherwise subject to any type of disciplinary action? *
Are you presently being investigated or is any disciplinary action pending against any professional license, certification, registration, or permit you hold? *
Have you ever been denied privileges at any facility? *
Seeking Position *
Which type of Position are seeking-Check all that apply
Required
Have your privileges ever been revoked at any facility? *
Have you ever been convicted of a felony? *
Are you receiving or have you received therapy, treatment, or counseling for any alcohol or drug abuse or related condition? *
Have you ever been named in a lawsuit?
Have you ever been denied professional liability insurance coverage or been rated at higher than average risk class for your specialty? *
Are any specific procedures excluded from your present professional liability insurance carrier? *
EXPLANATIONS/REMARKS/COMMENTS
If you answered yes to any of the previous questions please write an explanation in the box below.
Your answer
SKILLS/CLINICAL COMPETENCIES
Skills- Please check all in which you are proficient. *
Only include those in which you have had personal hands-on experience in providing.
Required
Skills-of the skills checked above, are there any you would not feel comfortable doing without a medically directing Anesthesiologist. *
Please use the box below to describe your answer
Your answer
Are you comfortable working in a practice setting by yourself without medical direction? *
Select the type of anesthesia administration you would feel comfortable administering without medical direction and without another CRNA with you. *
Required
Travel Time- Are you willing to travel -60-90 miles away to provide service? *
CREDENTIALS/VACCINATIONS
I have the selected items and all are up to date *
choose all that apply
Required
CALL
Are you willing to take Call From Home
This is for a Hospital Located in Richmond Missouri which is about 30 minutes East of World's of Fun
COMMENTS
Please provide a short summary as to why you desire to be a member of our staff. *
Your answer
Further Remarks From Applicant
This is where you may add any additional comments you feel are important that weren't already addressed in the questionnaire.
Your answer
ATTESTATION
Attestation- *
Required
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