Date:  

Contract on File:  Yes  No

* Hospital:  

or * Group:  

Please List how you would prefer your contract to be written.
If group covers for more than one facility please let us know if you will need staffing for those.

* Contact Person:  

* Title:  

* Address:  

* City:  

* State:  

* Zip:  

* Phone:  
 

XXX-XX-XXXX

Fax:  
 

Hospital Statistics
Please fill complete as accurately as you can information regarding your OR’s current set up.
 

# OR:  
 

# CRNA:  
 

# Required to be at full staff

# Beds:  
 

# MDA:  
 

# Required to be at full staff

# Bassinets:  
 

# Anesthesia Assistants:  
 

# Required to be at full staff

# Recovery Rooms:  
 

# Surgeons:  
 

# Cases per Month:  
 

Positions Specifics
Please tell us about the position available so that we may
better qualify candidates to meet your needs.
 

Start date of coverage:  

Position:  

Chief  Solo  Staff

Exprience  New Grad

Shift Hours:  

Hours per Week:  

Call Required:  

Yes  No

Day off after Call:  

Yes  No

Call Frequency:  

Call Via:  

Beeper  In House

Weekend Call:  

Yes  No

Medically Directed:  

Yes  No

Drug Induction:  

CRNA    MDA
Both

Skills Required
Please check the skills required for position.

Regionals  

Retrobulb  

Blocks  

Spinals  

Bier  

CVP  

EPI’s  

A-Lines  

MAC  

Hearts  

Neuro  

PEDS  

Equipment
Please check the appropriate box with the types of anesthesia
monitoring equipment used by your facility.

Pulse Oximeters  

End Tidal CO2 monitors  

 
Patient Files 

Standard Written Charting  

Computerized Charting  

 
Describe why this position is available and the type of
employee you are looking for that would best fit your facility.