POLYSOMNOGRAPHY TECHNOLOGIST
PROFESSIONAL PROFILE

If you prefer, you can print a form to fax or mail.

     Last Name: 
    First Name: 
Middle Initial: 
Profession:
 RRT      Years Experience
 CRRT     Years Experience
 POLY     Years Experience
 RPSGT    Years Experience

INSTRUCTIONS:
1. Please print or type clearly.
Complete only those items that apply to your profession.

SPECIALTIES: [Please check all areas in which you are qualified and experienced to work.]

NICU     PICU     ICU     MICU     SICU

Other:      Other:

Other:      Other:

* PROFESSIONAL LICENSURE: 

License #:  State:      License #:  State: 
License #:  State:      License #:  State:
* CERTIFICATIONS:
- BLS/CPR     - ACLS     - NALS     - PALS
- Other:      - Other: 
- Other:      - Other:
CHICKEN POX STATEMENT:
- Yes, I have had chicken pox
- No, I have not had chicken pox

 

FACILITY/SPECIALTY PREFERENCE
1st Choice: 
2nd Choice: 
3rd Choice: 
Submitted by:  Date: 
Phone / Email:
* Reminder: include photocopies of both sides of all professional licenses, registrations, and certifications. 
©Rapid Temps, Inc, rev 12-99

Press 'Register' to send the form to us and proceed to the Skills Proficiency Checklist.
 
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