Five Star Anesthetists - CRNA, nursing and staffing placement services

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Information for Healthcare Facilities

Please complete this form so that we may contact you appropriately regarding services to your facility.


CONTACT INFORMATION:
Client Name:
Hospital Name:
Location:
Contact Person/Title:	Zip:
Telephone:
Fax. Tel:
Administrator who will be signing contracts/Title:
E-mail:
Where did you hear of CRNA Services:
How many CRNAs do you wish to hire:
When are they to begin:
Do you desire full or part time employees:	Full Time Part Time
Are you interested in new graduates:	Yes No
Would you consider LTs awaiting placement:	Yes No
FACILITY:
Are you a:	Medical Center Community Hospital Surgicenter Other
Number of beds:
How many M.D.s:
How many CRNAs:
How many anesthetics are administered each year:
What makes your facility stand out from others:
JOB DESCRIPTION:
Please enter the job description in the box:
SPECIALTY AREAS Check all that apply Major Vascular Neuro Obstetrical Open Heart Pediatric Trauma ENT Endo Ortho Opthalmology General Other:	SPECIAL SKILLS Do CRNAs insert invasive monitoring? Yes No A-Lines Yes No CVP Lines Yes No Swan-Ganz Yes No Do CRNAs administer regional anesthesia? Yes No IV Regionals Yes No Axillary Blocks Yes No Spinal Anesthesia Yes No Epidural Anesthesia Yes No

SUPERVISION:
Who supervises the CRNA:
To what extent:	Heavy Medium Light
SALARY & BENEFITS: Please itemize your benefits
Salary:
Pension:
Profit Sharing:
Bonus:
Medical Expenses:
Professional Expenses:
Health Insurance:
Disability Insurance:
Dental Insurance:
Professional Liability Insurance:
Life Insurance:
Parking:
Vacation Time:
Paid Holidays:
Sick Time:
Personal Days:
Professional Days:
Other:
WORK COMMITMENT:
What is the average number of hours the CRNA works each week:
How Frequently do CRNAs take call:
In house or out of house call:
How frequently are CRNAs called in each night or weekend:
What compensation do they receive:
EXPENSES:
Will you reimburse the candidate for expenses resulting from the interview? (i.e., travel, hotel, etc.):	Yes No
If so, which:	Airfare Rental Car Mileage Lodging Per Diem
Will you assist the anesthetist with relocation expenses? :	Yes No
COMMUNITY:
Please elaborate as much as possible on the community where you are located (i.e., size, culture, entertainment, recreation, housing, schools, etc.) City Community Rural
COMMENTS:
If there are any additional details that you feel we should know, please elaborate: