Travel Co._________________________________Recruiter_____________________________
Name of Hospital_______________________________________________________________
Contact Person____________________________Number_______________________________
Hospital Location_____________________________________ No. Of Beds_______________
Website ______________________________________________________________________
No. of Floors____________________ Separate Buildings?______________________________
Hospital Age__________________________ How Big Unit____________________________
Salary_________________________ Shift Diff._________________ Bonuses______________
Shift Hrs_________________# Hours/Days Per Week_______________ O.T. ______________
Assignment Start Date_____________________ Length_______________________________
Extend___________________________ Cancellation Policy____________________________
Type of Nursing Unit____________________________________________________________
_____________________________________________________________________________
Type of Patients________________________________________________________________
_____________________________________________________________________________
Isolation Pt. _______________________ Vents_____________ Hearts___________________
Avg. Pt. Age___________________Pop________________Inmates_______________________
Nurse/Patient Ratio Days________________________ Nights___________________________
Supervisory Method___________________ House Supervisor___________________________
Support Staff______________ Charge Nurse________________ Nurse Aides______________
Unit Sec__________________ Lab Tech___________ PT_____________RT______________
Charting Method________________________________________________________________
Night Shift Duties_______________________________________________________________
Day Shift Duties________________________________________________________________
Medication Sys._______________________________ Supply Sys.______________________
Pharmacy Open Nights____________________________Pharmacist_____________________
Scheduling______________________________ Schedule Length________________________
On Call________________________________ Holiday Scheduling_______________________
Request Days Off________________________ Work Certain Days_______________________
Float other floors_________________________ Other Hospitals__________________________
Uniforms___________________________________ Parking Charges_____________________
Many travel Nurses?_____________________________________________________________
Seasonal Work?______________ Called Off___________ Contract Canceled ______________
Lunch_____________________ Breaks______________________ Lockers________________
Cafeteria Open________________ Discount_____________ Food Good?__________________
Inservice ___________________________________ CEU______________________________
Town Stats-Name___________________________Website_____________________________
What is the City Like?___________________________________________________________
How Far Natural Entertainment?___________________________________________________
Diving/Snorkeling?____________________________Camping__________________________
Local Entertainment_____________________________________________________________
Town Population___________________Locals_________________Tourist_________________
Temp Spring________Summer________Fall__________Winter_________Hurricane_________
Rain ____________________ Snow ___________________ Pollution____________________
Nearby water________________Beach____________________Parks_____________________
What is City Famous for? ________________________________________________________
Year town Established ? __________________________________________________________
Housing Stats
Provided by Travel Co ______________________or Hospital____________________________
Housing Choices?___________________________ Apt. Location_______________________
Apt. Name_________________________________ Contact Person_______________________
Phone _____________________________ Website ___________________________________
When Built ?__________________Remodeled? _______________________________________
No. of Apt.’s _______________________ Buildings ______________ Floors_______________
Cost_____________Deposits______________________Bedrooms____________Bath_________
W/D________Dishwasher________Refrig._________ Microwave ________ Stove __________
Furniture______________________________________________________________________
Ceiling Fans______________ Carpet____________ Tile__________
Balcony or Yard ________ Trash Service_________________
Pool_______________Spa___________Gym____________Pets_____________Dep.________
Construction nearby?____________ Lawn Care Days_____________ Busy Hwy____________
Covered Parking__________ Garage _____________ Opener _________Gates______________
What part of town ___________________________________Safe area____________________
Noise, hear neighbors, cars_________________________ View__________________________
Time drive to hospital_______________________ Miles to hospital ____________________
Traffic________________________________
Follow Up:
Received my File______________________________________________________________
What I Told Interviewer__________________________________________________________
What they told me_______________________________________________________________
Follow-Up Appt._______________________________________________________________
Contacted Recruiter_____________________________________________________________
Accepted Assignment ___________________________________________________________
Documents Needed______________________________________________________________
License_______________ Certifications_________________ Other_______________________