Prescreen Form

General Information

Applicant Name:

Netsai caroline choto

Date:

**/**/****

Requisition Title:

Patient Care Tech

Interest and History

Why are you currently in the job market and why are you interested in this position?

I have worked as a CAN for 26 years an I enjoy my job

How many years of PCT/CNA experience do you possess in a hospital setting?

26

Please explain any gaps in employment.

02/26/2022 medical leave/ emergency

Do you have High School Diploma or Equivalent (GED)? If you have College Degree/Diploma, please list.

YES NO

Are you enrolled in an accredited Nursing Program? If yes, have you completed the Fundamentals of Nursing? Please specify:

YES NO

YES NO

Or do you hold a current and active CNA License? If yes, in which state are you certified?

YES NO

State: texas

Or have you completed a PCT Training through NHA, NAHP, NCCT?

YES NO

Or have you completed an EMT training? (EMT-B)

YES NO

If yes, please list Certification Number, Issue Date, Expiration Date and Certifying Body.

Number:

Issue Date:

Expiration:

Certifying Body:

Do you hold current and active BCLS Certification? If yes, please list Certification Number, Issue Date, Expiration Date and Certifying Body.

YES NO

Number:

Issue Date:

Expiration:

Certifying Body:

Have you ever been a THR employee? If so, when, where, and why did you leave?

YES NO

When:2022

Where:Med/Surg

Why did you leave: medical

Do you currently work for UTSouthWestern?

YES NO

Are you currently or have you worked for THR as a Contract Worker? If yes, what agency do you or have you worked for?

YES NO

Name of Agency:

Do you have any relatives or a close relationship, current or former, that work for THR? If so, what is their name(s), entity, department, role, and relationship to you?

YES NO

Name(s):

Entity:

Dept/Role:

Relationship:

Expectations

What schedule are you willing to work? Are you looking for PRN/Part-Time/Full-Time

Full Time Days

Part Time Nights

PRN Evenings

Do you require specific days off?

Yes

If you are selected for interview, what is your availability to interview?

Anytime

Available to start?

As soon as possible

What is your hourly salary expectation? The pay range is $15/hour to $23.85/hour based on relevant experience.

$22/hr

Disclosures and Additional Information

Hiring is contingent on the successful completion of a criminal background check and a drug screen.

THR employees are required to have the flu vaccine administered during flu season and both doses of the COVID 19 vaccine(s) prior to starting unless you can provide a medical or religious exemption not to receive the vaccines.

Certain departments and employees are required to undergo High-Level Personal Protective Equipment (PPE) training at regular intervals.

If you are selected for this role, as a new employee you are required to participate in Texas Health Resources’ New Employee Orientation between 1-5 days. Your Onboarding Navigator will provide you with information regarding orientation. Please confirm that you will be able to attend.

YES NO

What is the best method to contact you?

469-***-****

01/06/2021

Contact this candidate