Nurse Assessment Form

 Contact Information

Prefix: *
 
First Name:*
  
Last Name:*
  

Profession/
Job Title:

  

Nursing Specialties:

(Please press control to choose more then one country)
  
Allied Health Specialties:
  
Address:
            
City:
  
Provence/State:
  
Postal/Zip Code:
  
Country:
  
E-Mail Address:*
  
Home Phone:
 
Work Phone:
  
  Country Code/Area Code/Number   Country Code/Area Code/Number
Cell Phone:
  
Facsimile:
 

How were you referred to Mentor:
 
Do you have regular access to a computer/Internet? Yes No

Education
 
 NAME & ADDRESS: DATES ATTENDED: DEGREE EARNED:
Nursing Education:

Certifications and Other Programs:

Certifications and Other Programs:
 

Certification Examinations

 
 DATE COMPLETED: SCORE:
CGFNS:

CRNE:

NCLEX:

TOEFL:

IELTS:

OTHER:

 

Licensure
Are you currently a licensed Registerd Nurse? Yes No
State of Licensure: License Number: Date of Exam: Expiration Date:
       
       
       
     

 

Courses and Certification

 
Please describe any additional courses you have taken or certification you have received as it relates to your profession:  

 

 

Current Employment

Hospital name:

          
Hospital beds:

Hospital address:


 
Hospital telephone:

Hospital Fax:

Country Code/Area Code/Number

 

Country Code/Area Code/Number
Specialty:

Hours worked/week:

Position/Title:

E-Mail address:

Date started:

Supervisor:

Telephone:

Fax:

 

Country Code/Area Code/Number

 

Country Code/Area Code/Number
May we contact your direct Supervisor for a reference? Yes No  

 

 

Previous Employment

 
Hospital name:

          
Hospital beds:

Hospital address:

 
Hospital telephone:

Hospital Fax:

Country Code/Area Code/Number

 

Country Code/Area Code/Number
Specialty:

Hours worked/week:

Position/Title:

E-Mail address:

Date started:

Supervisor:

Telephone:

Fax:

Country Code/Area Code/Number Country Code/Area Code/Number
May we contact your direct Supervisor for a reference? Yes No  

Previous Employment
Hospital name:

          
Hospital beds:

Hospital address:

 
Hospital telephone:

Hospital Fax:

Country Code/Area Code/Number

 

Country Code/Area Code/Number
Specialty:

Hours worked/week:

Position/Title:

E-Mail address:

Date started:

Supervisor:

Telephone:

Fax:

 

Country Code/Area Code/Number

 

Country Code/Area Code/Number
May we contact your direct Supervisor for a reference? Yes No  
 
 

Mandatory Legal Inquiries
Have you ever been convicted in a court of law or pleaded nolo contendere to an offense other than a minor traffic violation?

Yes No

If yes, please explain:

 
Has your nursing license ever been investigated, suspended or revoked?

Yes No

If yes, please explain:

 
Do you have any malpractice suits
(past or pending)?

Yes No

If yes, please explain:

 
Do you hold a valid passport?

Yes No

   

  Country Expiration Date:  
 

English Language Proficiency
Speaking proficiency:

High

Moderate

Low
Reading proficiency:

High

Moderate

Low
Writing proficiency:

High

Moderate

Low
 

Geographic Preference
Please indicate your country or program of preference:

 
Please indicate your country or program of secondary preference :