Project CODE CARE – Nursing Application Form – Ministry of Health & Wellness, Jamaica

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Project CODE CARE – Nursing Application Form

SECTION A – PERSONAL INFORMATION

APPLICANT

Name(Required)

Title First Middle Last

Date of Birth(Required)

DD dash MM dash YYYY

Gender(Required)

Male

Female

ADDRESS INFORMATION

Permanent Address(Required)

Street Address 1 Street Address2 Town/City Parish/State ZIP / Postal Code Country of Residence

Mailing Address (if different from permanent address)(Required)

Same as previous

Street Address 1 Street Address2 Town/City Parish/State ZIP / Postal Code Country of Residence

Nationality(Required)

CONTACT INFORMATION

Primary Telephone Number(Required)

Secondary Telephone Number(Required)

Email(Required)

What is your preferred means of contact?(Required)

Email

Phone Call

Text

SECTION B – PROFESSIONAL INFORMATION

PROFESSIONAL TRAINING

What is your highest level of education?(Required)

Certificate

Diploma

Bachelors

Masters

PhD

Education and Other Training(Required)

School Name

Location

Years Attended

Certification/Degree

Specialist Nursing Certifications(Required)

REGISTRATION AND LICENSURE

Are you currently registered and licensed in your country?(Required)

Yes

No

When is the expiration date?(Required)

DD dash MM dash YYYY

What is the name of the registration and licensing body?(Required)

Have you ever been registered and licensed in Jamaica?(Required)

Yes

No

Do you have current registration and licensure with the Nursing Council of Jamaica?(Required)

Yes

No

When is the expiration date?(Required)

DD dash MM dash YYYY

Do you have current registration and licensure with the Nursing Council of Jamaica?(Required)

Yes

No

EMPLOYMENT INFORMATION

Employer's Name(Required)

How many years have you been working with your current employer?(Required)

Less than a year

1 year – 5 years

Over 5 years

Job Title/Position(Required)

Employer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

SURGICAL EXPERIENCE
I AM EXPERIENCED IN SCRUBBING FOR THE FOLLOWING SURGICAL PROCEDURE(S)

Hernia Repair(Required)

Yes

No

Length of Experience(Required)

None

Less than a year

1 – 2 years

2 – 4 years

4 years or more

Fibroid removal/Myomectomy(Required)

Yes

No

Length of Experience(Required)

None

Less than a year

1 – 2 years

2 – 4 years

4 years or more

ENT procedures(Required)

Yes

No

Length of Experience(Required)

None

Less than a year

1 – 2 years

2 – 4 years

4 years or more

Plastic surgeries(Required)

Yes

No

Length of Experience(Required)

None

Less than a year

1 – 2 years

2 – 4 years

4 years or more

Length of experience in post anaesthetic care/recovery room care(Required)

None

Less than a year

1 – 2 years

2 – 4 years

4 years or more

SECTION C – TRAVEL INFORMATION

How much notice do you require prior to engagement?(Required)

Days

Weeks

Passport Number(Required)

Date of Issue(Required)

DD dash MM dash YYYY

Date of Expiry(Required)

DD dash MM dash YYYY

Country of Issue(Required)

Country

Do you require a visa to travel to Jamaica?(Required)

Yes

No

Do you wish to use your own accommodation?(Required)

Yes

No

If yes, you may be required to provide your own transport to and from the medical facility.

PREFERED DATES OF TRAVEL: (engagement for 7 days or 14 days)

Departure(Required)

DD dash MM dash YYYY

Arrival(Required)

DD dash MM dash YYYY

EMERGENCY CONTACTS

EMERGENCY CONTACT #1

Name(Required)

First Last

Relation(Required)

Parent

Spouse

Relative

Friend

Primary Telephone Number(Required)

Secondary Telephone Number

Email Address(Required)

EMERGENCY CONTACT #2

Name(Required)

First Last

Relation(Required)

Parent

Spouse

Relative

Friend

Primary Telephone Number(Required)

Secondary Telephone Number

Email Address(Required)

Have you ever been convicted of a criminal offense (in any country)?(Required)

Yes

No

Are you pending any disciplinary actions?(Required)

Yes

No

COVID-19 VACCINE INFORMATION

Are you vaccinated?(Required)

Yes

No

Vaccine administered(Required)

PFIZER

ASTRAZENECA

JOHNSON & JOHNSON

SINOPHARM

MODERNA

Date of first dose(Required)

DD dash MM dash YYYY

Date of second dose

DD dash MM dash YYYY

Booster dose

DD dash MM dash YYYY

SECTION D – DOCUMENTATION UPLOAD

Ensure ALL uploads are scanned properly and important information and/or dates can clearly be seen.

Passport-sized Photograph(Required)

Accepted file types: pdf, png, jpg, Max. file size: 128 MB.

Curriculum Vitae (CV)(Required)

Accepted file types: pdf, png, jpg, jpeg, doc, docx, Max. file size: 128 MB.

Passport: Demographic (Information) Page(Required)

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 128 MB.

Birth Certificate(Required)

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 128 MB.

Nursing Licenses (Up-to-date)(Required)

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 128 MB.

Undergraduate/Graduate Degrees(Required)

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 128 MB.

Proof of Vaccination(Required)

Accepted file types: pdf, jpg, png, Max. file size: 128 MB.

Name

This field is for validation purposes and should be left unchanged.

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