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To Applicant: We apperciate your interest in our organization; we assume you that we are sincerely interested in your qualifications, The use of this form does not indicate that there are any positions open, and does not in any way obligate Perioperative Nurses, Inc. A clear understanding of your qualifications, background and work history will aid us in evaluating your application. We are an Equal Opportunity Employer.

DATE    DATE AVAILABLE TO BEGIN    SS#

NAME    MAIDEN NAME

ADDRESS    APT#    CITY    STATE    ZIP

All Applicants must have two forms of communication:

TELEPHONE# (HOME)   CELL#   WORK#   OTHER#

D.O.B.   STATE   CITY   County

POSITION APPLIED FOR:

RN/OR	CST/ORT
RN/PAR	OTHER
CST/PAR PRE-OP & POST-OP

Have you ever been known by or gone by any different name from the one listed on this application?
Yes   No

If yes, please list all other names:

Are there any hours/shifts you are unavailable to work? Yes No
If yes, please indicate the hours/shifts you are unavailable to work

Are you available to work weekends? Yes No

Are you applying for Full time Part time PRN

What days and shifts are you available for Mon Tues Wed Thurs Fri

6:30am-3:15pm 11:00am-7:00pm 2:30pm-11:00pm Other,explain

E-mail Address

How did you hear about us? Referred by?

EMPLOYMENT DATA (start with your most recent job, list and provide all the information requested below for the past seven (7) years.) Failure to provide all the information requested will delay the verification process.

WORKED	MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

WORKED	SECOND MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

WORKED	THIRD MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

WORKED	FORTH MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

WORKED	FIFTH MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

WORKED	SIXTH MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

WORKED	SEVENTH MOST RECENT EMPLOYER	POSITION
FROM DATE (MM/DD/YYYY)	COMPANY:
TO DATE (MM/DD/YYYY)	ADDRESS:	SUPERVISOR NAME:
	CITY: STATE: ZIP: County: PHONE # A/C:
	DUTIES / RESPONSIBILITIES	SHIFTS WORKED:
	ENDING SALARY /Hrly.
	REASON FOR LEAVING	# OR ROOMS

MAY WE CONTACT THE ABOVE MENTIONED EMPLOYERD?
YES NO, IF NO, WHICH ONES AND WHY:

SIGNATURE:

PLEASE EXPLAIN ANY PERIODS OF UNEMPLOYEMENT DURING THE LAST SEVEN (7) YEARS.

ACLS BCLS Certification YES NO
If yes, expiration date

(circle one, including a copy of your current CPR)

States in which you are currently licensed with:

STATES NUMBERS EXP. DATE

STATES NUMBERS EXP. DATE

HAVE YOU EVER BEEN DENIED A LICENSE OR CERTIFICATION, HAD A LICENSE OR CERTIFICATION REVOKED OR SUSPENDED, OR BEEN SUBJECT TO DISCIPLINE BY ANY LICENSING BODY, CERTIFYING BODY, AND / OR PROFESSIONAL AUTHORITY? YES NO, IF YES, PLEASE STATE WHEN AND DESCRIBE IN DETAIL.

HAVE YOU EVER BEEN THE SUBJECT OF A CLAIM OF MALPRACTICE OR NEGLIGENCE RELATING TO YOUR PROVIDING MEDICAL CARE, NURSING SERVICES,OR WORK AS A SURGICAL TECHNICIAN? YES NO, IF YES, PLEASE STATE WHEN, DESCRIBE IN DETAIL AND EXPLAIN THE DISPOSITION OF THE CLAIM.

HAVE YOU EVER HAD A COMPLAINT OR GRIEVANCE FILED AGAINST YOU WITH THE TEXAS BOARD OF NURSE EXAMINERS (OR ANY OF ITS PREDECESSORS OR A SIMILAR ORGANIZATION IN ANOTHER STATE?) YES NO, IF YES, PLEASE STATE WHEN, DESCRIBE IN DETAIL, AND EXPLAIN THE DISPOSITION.

HAVE YOU EVER APPLIED FOR OR WORKED FOR PERIOPERATIVE NURSES, INC. BEFORE? YES NO, IF YES, PLEASE GIVE DATES / EXPLAIN.

HAVE YOU EVER BEEN TERMINATED FROM WORK, TRAINING, OR AN EDUCATIONAL PROGRAM DUE TO THE QUALITY OF YOUR PATIENT CARE? YES NO, IF YES, PLEASE EXPLAIN.

ARE THERE ANY FACILITIES THAT YOU ARE UNAVAILABLE TO WORK FOR?

IF SO, PLEASE EXPLAIN WHY

PROFESSIONAL REFERENCES (important: please give accurate reference information.) only references with knowledge of your clinical skills may be listed.

NAME	ORGRANIZATION	PROFESSIONAL RELATIONSHIP TO YOU	HOME ADDRESS (CITY, STATE, ZIP, PHONE#)

EDUCATION (include address, county, and phone number) FAILURE TO DO SO MAY CAUSE A DELAY IN PROCESSING YOUR APPLICATION.

COLLEGE	NAME LOCATION County	MAJOR	FROM (MM/YYYY)	TO (MM/YYYY)	CIRCLE LAST YEAR 1 2 3 4	DID YOU GRADUATE	DIPLOMA DEGREE
OTHER (SPECIFY) SUCH AS MASTERS DEGREE CORRESP. COURSE	NAME LOCATION County	MAJOR	FROM (MM/YYYY)	TO (MM/YYYY)	CIRCLE LAST YEAR 1 2 3 4	DID YOU GRADUATE	DIPLOMA DEGREE

LIST PROFESSIONAL ORGANIZATIONS TO WHICH YOU BELONG:

LIST ANY SPECIAL TRAINING SKILLS/CERTIFICATION IN SPECIALTY AREAS:

CAN YOU, WITH OR WITHOUT REASONABLE ACCOMMODATION, PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED? YES NO

ARE YOU LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES? YES NO

PERSON TO MOTIFY INCASE OF AN EMERGENCY:

NAME RELATIONSHIP ADDRESS A/C PHONE #

NAME RELATIONSHIP ADDRESS A/C PHONE #

HAVE YOU EVER BEEN CONVICTED OF A CRIME, PLEAD GUILTY OR NOLO CONTENDERE IN A CRIMINAL MATTER, TAKEN DEFERRED ADJUDICATION IN A CRIMINAL MATTER, OR HAD A PROBATION OR SENTENCE (SUSPENDED OR OTHERWISE) IN A CRIMINAL MATTER?
YES NO

YOU SHOULD INCLUDE IN YOUR ANSWER CRIMINAL MATTERS REGARDLESS OF WHETHER YOU BELIEVE THEY HAVE BEEN EXPUNGED FROM YOUR RECORD, ARE NO LONGER ON YOUR RECORD, OR IF YOU HAVE SUCCESSFULLY COMPLETED A PROBATION OR HAD A SENTENCE SUSPENDED. YOU MAY EXCLUDE FROM YOUR ANSWER MINOR TRAFFIC OFFENSES BUT NOT DUI’S OR DWI’S. PLEASE NOTE THAT A “YES” ANSWER TO THIS INQUIRY WILL BE CONSIDERED IN ACCORDANCE WITH ANY APPLICABLE EEO LAWS AND FACTORS SUCH AS THE NATURE AND GRAVITY OF THE OFFENSE(S), THE TIME THAT HAS PASSED, AND THE NATURE OF THE JOB SOUGHT, IN EVALUATING YOUR SITUATION ? YES NO ,IF YES, PLEASE EXPLAIN

I certify that the information I have provided in this application, any supplement thereto, in my resume, and throughout my application process is true and complete to the best of my knowledge. I understand that false, incomplete, or misleading statements given on this application, any supplement thereto, in my resume, in connection with the application process or interview(s) will result in rejection of this application. I understand that if employed, false, incomplete, or misleading statements given on this application, any supplement thereto, in my resume, in connection with the application process or interview(s) will result in dismissal. I authorize investigation of all statements provided in conjunction with this employment application as may be necessary in arriving at an employment decision. I hereby release Perioperative Nurses, Inc. as a condition of employment. I understand that if hired, I may resign at will, or without cause or prior notice, and that Perioperative Nurses, Inc. will employ me “at will” and that I may be terminated, with or without cause or prior notice, except where provided otherwise by law, No, supervisor, representative, agent or employee of the company has now or has in the past any authority to enter into any agreement for employment for a specified period of time or to make any agreement which is contrary to or a modification of the above terms, nor can any policies of the company either written or oral, modify this “at will” status. I understand that, if I am hired and paid a salary for the particular term (ex-week, month, year) by Perioperative Nurses, Inc. this is not intended to create any agreement to employ me for that term.

I understand that, if hired, I may be referred by Perioperative Nurses, Inc. to be considered for or to actually perform work at one of its clients. I hereby consent to Perioperative Nurses, Inc. releasing to any one of theses clients, to whom I am referred for consideration for work or for whom I actually perform work, any written information (including personnel information or evaluations) which Perioperative Nurses, Inc. has now or obtains in the future about me. I release Perioperative Nurses, Inc. and its officers, directors, agents, and employees (past or present) from any liability for releasing such information about me.

SIGNATURE OF APPLICANT DATE

PERIOPERATIVE NURSES, INC.

COMPETENCY SKILLS CHECK LIST

Name Date Years Experience

Instructions: Please Place A 1,2 or 3 By Each Procedure According to Key
C = Circulate     S= Scrub

KEY:
1. No experience-Or have done less than 5 times.
2. Moderate-Comfortable with resource person available.
3. Extensive-Done frequently fell comfortable without assistance.

GENERAL RN COMPETENCY

SCREENING TEST

NAME DATE Validate By

 

1. The Steris system1 offers high-level disinfection only, not sterilization. Ans.

1. True
2. False

2. Before taking a Sterised tray to the operating room, you should always: Ans.

1. Check for complete aspiration of the sterilant.
2. Review the sterile processing printout for verification of parameters.
3. Rinse the items with sterile water.
4. A&B
5. B&C
6. All of the above.

3. The processing container can be placed into the processing tray in any position. Ans.

1. True
2. False

4. The three process parameters critical to the Steris process are: Ans.

1. Exposure time, pressure and activation date of the sterilant.
2. Exposure time, pressure and concentration of the sterilant.
3. Exposure time, temperature and concentration of the sterilant.

5. When practicing universal precautions a case is considered contaminated Ans.

1. If you encounter purulent drainage during a procedure
2. All cases are treated as contaminated cases
3. If the patient has an infection
4. None of the above

6. According to AORN, instrument counts should be performed Ans.

1. Concurrently with the scrub and circulator
2. On all procedures with an open major cavity
3. Individually and by name
4. All of the above
5. None of the above

7. When an instrument, sponge or sharp count is incorrect an X-ray must be taken Ans.

1. Before the patient leaves the OR
2. If the surgeon requests one
3. If the OR supervisor deems it to be necessary
4. Never

8. You relieve the scrub person but are not sure what the clear fluid is in a medicine cup on your back table. There is am empty vial labeled 0.25% Marcaine in the room, but the original circulator who dispenses the drug has been relieved as well. You should: Ans.

1. Assume the clear liquid is 0.25% Marcaine
2. Label the clear fluid 0.25% Marcaine so the next scrub person will know what it is
3. Ask the surgeon what medications he has administered
4. Discard the liquid

9. Prior to positioning a patient, the nurses should access the patient for: Ans.

1. Physical limitations and weight
2. Height and nutritional status
3. Skin condition, pre-existing disease and length of procedures
4. All of the above

10. Even during short procedures in the prone position, genitalia and breasts need to be protected from pressure. Ans.

1. True
2. False

11. When retrieving instruments from the autoclave, the nurse/tech should verify which of the following have been achieved. Ans.

1. Correct time
2. Correct cycle
3. Correct temperature
4. All of the above

12. When selecting the site for placement of the return electrode, one should consider. Ans.

1. The location of the incision.
2. The patient surgical position.
3. The area to be prepped.
4. Other equipment that will be used for the case.
5. All of the above
6. None of the above

13. When preparing a child for surgery, it is espcially vital to check for loose teeth in which age group? ... Ans.

1. Older infant
2. Toddler-Preschool
3. School Age - Elementary
4. Adolescent

14. Which of the following data is most helpful to the nurse in evaluating a young child's pain status? ........Ans.

1. A verbal statement of pain.
2. Physiologic changes.
3. Behavioral changes.
4. Parental comments.

15. Metal with lumens or porous items that are sterilized together in a gravity displacement sterilizer should be flash sterilized at____for____minutes. Ans.

1. 270 degrees Fahrenheit: 10
2. 270 degrees Fahrenheit: 3
3. 275 degrees Fahrenheit: 6
4. 275 degrees Fahrenheit: 4

16. Before opening a sterile package, one should do which of the following? Ans.

1. Inspect the integrity of the package
2. Check for the expiration date
3. Verify process monitors
4. All of the above

17. Unsterile, unscrubbed individuals should Ans.

1. Not lean or reach over the sterile field for any reason
2. Not walk between two sterile fields
3. Always face the sterile field when approaching
4. None of the above
5. All of the above

18. From the statements listed below above delivering solutions to the sterile field, select the statment that is false. Ans.

1. The entire bottle contents should be poured into the receptacle or the bottle recapped.
2. The solution receptacle should be placed near the edge of the table or held by the scrubbed person.
3. Fluids should be poured slowly to avoid. splashing.
4. The entire bottle contents should be poured into the receptacle or the remainder discarded.

19. The following statements about the documentation of prioperative nursing care are true except. ........Ans.

1. The patient's record should reflect the nursing process performed by the perioperative nurse.
2. The patient's record should reflect the preoperative assessment performed by the surgical technologiest.
3. The patient's record should identify persons providing care during the perioperrative phase of care.
4. The patient's record should reflect continual evaluation of the perioperative nursing care and the patient's response to nursing interventions.

20. From the following statements about the return electrode, select the statement that is true Ans.

1. The dispersive electrode may be placed over hairy surfaces, bony prominence, scar tissue or distal to tourniquets.
2. The status of the dispersive electrode and its connection to the ESU should be checked if the patient is repositioned.
3. The dispersive electrode may be placed on the skin over an implanted metal prosthesis provided that it is in good contact with all skin surfaces.
4. Tissue perfusion does not affect electrical conductivity or heat dissipation, so the electrode can be placed over scar tissue.

21. It is recommended that when using electrocautery, the highest power setting possible be used to achieve the desired effect. Ans.

1. True
2. False

22. Laser-safe eye protection with appropriate wavelength and optical density should be worn by: Ans.

1. The scrub person and operating surgeon.
2. The scrub person, operating surgeon and assistants.
3. All personnel in the hazard zone.
4. The scrub person, operative surgeon, assistants and anesthesia provider.

23. When the patient is in the lithotomy position: Ans.

1. Raising the legs quickly and lowering them slowly and simultaneously compensates for venous return and minimizes the possibility of joint damage.
2. Raising and lowering the legs slowly and simultaneously may help compensate for venous return and prevent joint damage.
3. Raising the legs slowly and lowering them quickly and simultaneously compensates for venous return and prevents joint dislocation.

24. Becuase of the potential contamination by human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens, all instruments that were on the sterile field but not used should be considered infectious. Ans.

1. True
2. False

25. Standard precautions apply to exposure____, ____, and ____: Ans.

1. Urine; feces; excretions except sweat
2. Blood; saliva; urine
3. Blood, all body fluids; excretions
4. Urine; blood; saliva

Perioperative Nurses, Inc.

Perioperative Staff Nurse Job Description

I. General Information

The following statements reflect the general position descriptions necessary to function on the job, and shall not be considered as a detailed description of all work requirements that may be inherent in the position. PNI nurses are obligated to follow all the policies and procedures of the company, including those that are adhered to by nurses in each client family.

II. Qualifications

Must have a minimum of two years current (within the last two years) experience as an R.N. in the operating room, and maintain proof of a current license, CPR and annual mandatory in-service. Must demonstrate a working knowledge of and comply with AORN standards.

III. Organizational Status

Reports directly to PNI, Chief Clinical Officer. When in the clinical setting of the client’s facility, receives direct supervision from the Director, Head nurse/nurse manager or Assistant Head nurse/ nurse manager of PNI’s client.

IV. Position Summary

Coordinate patient care in a single Operating Room unit and provide direct nursing care in collaboration with the physician and other members of the healthcare team.

V. Essential Job Functions

Reports for duty promptly at assigned time and appropriate OR attire. Confidently assumes role function(s) when caring for the surgical patient in a single OR unit.

A. In the role of a scrub nurse     Heavy

B. In the role as a circulating nurse     Heavy

VI. Additional Daily and Essential Job Functions

1. Good Attendance and dependability
2. Ability to frequently bend, lift stoop, push, pull and stretch to position and/or move patients, equipment and etc. requiring manual dexterity      Heavy
3. Extensive walking and standing     Heavy
4. Ability to function satisfactorily in stressful situations.     Heavy
5. Ability to sustain work load involving quick movements and manual dexterity     Heavy
6. Maintain positive interpersonal relationships with co-workers, other personnel, physicians and patient families
7. Effective, harmonious communication (both oral and written). Good listening skills
8. Compliance with lawful policies of PNI, its client’s and with lawful requests for any job description of hospital or client whose premises the individual works
9. Complies with applicable standard of care for work
10. Demonstrates basic principles of ethical behavior in the care of patients while including family and significant others in the assessment and care of patients, as appropriate
11. For patients with special needs, seeks assistance to acquire services (i.e. translators, etc.) and ensure safety of patients
12. Documents information on patients consistent with established protocol and guidelines. Gives concise and pertinent reports regarding patient and unit related information including rational explanations for action/interventions based on current practice standards and proven experience and etc.
13. Accepts clinical assignments that are consistent with education, licensure and competence to care for patients. Engages in cross-training. Uses basic interviewing techniques to obtain patient data on biophysical, psychosocial, environmental, self care, educational and discharge planning aspects of patients.
14. Correctly uses basic skills for administering medications.
15. Demonstrates knowledge and responsibility, both legal and ethical, in administering narcotics, alcohol, controlled substances and/or mind altering drugs.
16. Requires ability to read, prioritize and monitor time
17. Requires critical thinking and ability to problem solve. Ability to communicate appropriate information to patient, family members and staff. Requires skills necessary to read, process orders and manual documentation. Requires hearing acuity (heart, lungs, bowel sounds, etc.)
18. Is positive and supportive of change and demonstrates flexibility in adjusting work hours to ensure that sufficient qualified staff are available to meet patient needs
19. Participates in peer review process and is effective in team work and group interaction. Is supportive of new employees and students.
20. Requires critical thinking and ability to problem solve through the nursing process.
21. Implements actions/recommendations to improve unacceptable performance
22. Maintains professional appearance and decorum
23. Assumes accountability for own continuing professional development and competence, including current licensure and CPR certification

* Determined by the type of physical activity involved in doing each job function and categorized as Sedentary, Light, Medium, Heavy and Very Heavy.

** Manual Dexterity 25 lbs. Or more from floor to waist, waist to chest, chest to over head, and twisting and turning is required frequently on a daily basis.

I have received and reviewed the above job description.

Employee Signature   Date  

DRUG AND ALCOHOL ABUSE POLICY OF

PERIOPERATIVE NURSES, INCORPORATED

1. PURPOSE AND SCOPE OF POLICY

Drug abuse poses a danger to all of us. Drug abuse impairs safety and health, promotes crime, lowers productivity, and may undermine confidence in the performance of our work. It is the intent of Perioperative Nurses, Incorporated ("PNI") to maintain a drug free work place. Additionally, the Texas Worker's Compensation Act requires that PNI adopt and maintain a policy designed to eliminate drug abuse in the work place. This policy has therefore been adopted to provide employees of PNI with a statement of PNI's position and policy regarding the use and possession of alcohol and controlled substances. Please note that this policy includes and covers alcoholic beverages as well as inhalants and illegal drugs.

All employees of PNI will be required to strictly and fully comply with the terms and requirements of this policy as well as those of clients that contract with PNI. This policy will apply to all applicants for employment, and to each employee of PNI during the employee's regular work hours, at any time while the employee is acting in the course and scope of his/her employment for PNI, and any time a PNI nurse is performing services or acting on behalf of PNI on the premises of one of PNI's clients (collectively "PNI Time"). This policy is applicable at PNI's offices and in all other locations where PNI employees perform services, nursing or otherwise (collectively "PNI Work Locations"). Provided, however, that the prohibitions concerning alcoholic beverages contained in this policy shall not be applicable at PNI functions which are social in nature.

2. POLICY STATEMENT

a. All employees are prohibited from unlawfully manufacturing, consuming, distributing, dispensing, processing, being under the influence of, or using any Controlled Substance on PNI Time or at PNI Work Locations. For purposes of this policy, the term "Controlled Substance" shall mean any controlled substance included in Schedules I through V of Title 21 of the United States Code, Section 812, and shall also include any illegal drug, look-alike, inhalant, designer or synthetic drug, or any other unauthorized drug or dangerous substance which may negatively affect a person's mood, senses, responses, motor functions, or alter or affect a person's perception, performance, personality, judgment, reactions or senses.

b. All employees are prohibited from consuming, distributing, dispensing, possessing, being under the influence of, or using any alcoholic or intoxicating beverage on PNI Time or at PNI Work Locations.

c. The sale, possession or use of any of the following items on PNI Time or at PNI Work Locations is likewise strictly prohibited:

(i) Drug-related paraphernalia, including, without limitation, any material or equipment designed for use in testing, packaging, storing, injecting, ingesting, inhaling, or otherwise introducing into the human body alcohol, any intoxicating beverage, or any Controlled Substance.

(ii) Firearms, weapons, or explosive materials, including without limitation, any type of gun, illegal knife, or other dangerous instrument.

d. Each employee is additionally required to familiarize himself/herself with and strictly and fully comply with the lawful terms and requirements of the drug and alcohol abuse policy of any of PNI's clients for whom that employee performs services.

e. The prohibitions of this policy concerning Controlled Substances do not apply to a health care professional's authorized and lawful possession or dispension of such substances in the proper course of that person's duties as a health care professional.

f. The prohibitions of this policy do not apply to an employee's lawful possession and use of Controlled Substances as per a physician's order or prescription.

3. DRUG TESTING POLICY

PNI requires all applicants for work to submit to a blood test, urinalysis or other medically or legally recognized investigatory test or procedure (collectively referred to as a "drug screen"). The results of these tests may be utilized by PNI to determine the tested applicant's fitness for employment.

Additionally, PNI reserves the right at any time, and without prior notice to employees, to require one or more employees, whether specifically chosen or chosen at random, to submit to a drug screen as a condition of continued employment. The results of these tests may be utilized by PNI to determine the tested employee's fitness for continued employment, and to determine the presence of any substance prohibited by this policy in the system of the tested employee. Factors which may result in a specific employee being required to submit to a drug screen may include, but are not limited to:

a. Manifestation by the employee of signs of intoxication or of being under the influence of a substance prohibited by this policy, or other observations that would lead a prudent supervisor or other employee to be concerned about the individual's safety, the safety of other employees, the safety of our patients, or of the general public.

b. In the event PNI has any cause to believe that a specific employee or group of employees is possessing, using, or under the influence of any substance or item prohibited by this policy.

c. In the event any employee or other person is found to be in possession of a substance or item prohibited by this policy while on PNI Time or at PNI Work Locations.

d. In the event an employee suffers an occupational "on-the-job" injury, or in the event of a serious or potentially serious accident or incident in which safety precautions were violated, equipment or property was misused or damaged, or careless acts were performed.

e. In the event an employee returns to work following an extended illness, disabling injury, extended absence, or reduction in work force.

f. In the event of manifestation by an employee of other signs or symptoms of drug use or abuse, such as drastic mood changes, abusive behavior, frequent tardiness or absenteeism, and chronic physical symptoms such as fatigue, dry cough, sore throat, or conjunctivitis.

The listing of the foregoing factors is not intended to and shall not limit the right of PNI to require any employee to submit to a drug screen at any time.

In the event an employee is requested to submit to a drug screen, the employee will be required to go immediately to a physician or laboratory facility selected by PNI for such drug screen. Blood and/or urine samples collected by the physician or laboratory facility may thereafter be transported to another laboratory facility, if necessary or appropriate, for completion of the testing process. All test results will be read and interpreted by the physician or laboratory facility and such results will be provided to PNI. A positive test result with regard to any substance prohibited by this policy will cause the employee to be considered "under the influence" of that substance and shall be grounds for discipline of the employee, up to and including immediate discharge. The term "positive test result" is defined as the level of a particular substance designated by the particular physician or laboratory facility selected by PNI to do the drug screen.

When requested by PNI, drug screens will be conducted on PNI paid time and at PNI expense and will be mandatory.

At no time will an employee of PNI be subjected to a drug screen without the written consent of the employee. However, refusal by an employee to cooperate with PNI, the physician or laboratory facility in submitting to the drug screen, or to give his or her written consent to the drug screen, or any attempt to adulterate drug screen specimens or falsify test results will be grounds for discipline of the employee, up to and including immediate discharge.

4. TREATMENT PROGRAMS

At this time, there are no treatment or rehabilitation programs for Controlled Substance or alcohol abuse sponsored by PNI, and no such programs are available through the PNI's Worker's Compensation insurance carrier. Health insurance benefits and treatment for Controlled Substance or alcohol abuse are available to eligible full time PNI employees enrolled under PNI's helath plan, subject to the terms and conditions and exclusions of the applicable plan, which may be changed or terminated as allowed by law. All employees are encouraged to voluntarily seek assistance for alcohol and Controlled Substance abuse. However, voluntary reporting of Controlled Substance abuse problems does not relieve an employee of his or her responsibility to comply with PNI's Drug and Alcohol Abuse Policy and to meet all other work performance requirements.

In the event any employee desires to participate in a private drug-treatment program which would necessitate time off from work, the employee should notify PNI's administrative staff. The decision of whether to allow the employee time off for such purpose will be made on a case-by-case basis, and PNI reserves the right to deny such request to the extent permitted by law.

5. EMPLOYEE PROTECTION

All drug screens will be performed with respect for each individual's privacy and dignity. The results of all drug screens will be considered a confidential record and will be disseminated strictly on a "need-to-know-basis" within PNI, or on a "need-to-know-basis" to any of PNI's clients for whom that employee is performing services or acting on behalf of PNI, or as otherwise may be legally required.

6. AMENDMENTS TO POLICY

PNI may find it necessary to amend this policy from time to time, and to implement other practices and procedures deemed necessary or appropriate, or as may be required by state or federal law or regulation. Any amendment of this policy will be made in writing, and copies of the amendment will be distributed to all employees of PNI.

7. EMPLOYEE STATUS

All employees of PNI are "at-will" employees. Nothing contained in this policy shall be construed as modifying or affecting the employment "at-will" status of any employee.

ACKNOWLEDGMENT BY EMPLOYEE

I acknowledge that on this date I received a copy of the Drug and Alcohol Abuse Policy of Perioperative Nurses, Incorporated ("PNI"). I have read the policy or, if I am unable to read the policy, it has been read to me. I understand the policy in all respects and agree to abide by the policy as a condition of my continued employment. I acknowledge that PNI retains the right to amend the policy and the right to implement other practices and procedures deemed necessary or appropriate by PNI.

Signature of Employee

Employee's Printed Name

Date

EMPLOYEE CONSENT FORM

I hereby consent to undergo a blood test, urinalysis, or other medically or legally recognized investigatory test or procedure (a "drug screen") for the purposes of determining my fitness for continued employment by Perioperative Nurses, Incorporated ("PNI"), and for the purpose of determining the presence in my system of alcohol, illegal drugs, Controlled Substances, or other substances prohibited by the Drug and Alcohol Abuse Policy of PNI.

I understand that the drug screen will be administered by a physician or laboratory facility selected by PNI and will be done at PNI's expense. I agree to go immediately to the physician or laboratory facility selected by PNI to undergo the drug screen. I consent to the disclosure of the results of the drug screen to PNI and to clients of PNI for whom I am performing services or acting on behalf of PNI. I understand that a positive test result will cause me to be considered "under the influence" of that substance and will be grounds for disciplinary action against me, up to and including immediate discharge. I have not and will not make any attempt to adulterate drug screen specimens or falsify test results. A "positive test result" is defined as the level of a particular substance designated by the particular physician or laboratory facility selected by PNI to do the drug screen.

Signature of Employee

Employee's Printed Name

Date

APPLICANT CONSENT FORM

I hereby consent to undergo a blood test, urinalysis, or other medically or legally recognized investigatory test or procedure (a "drug screen") in connection with my application for employment by Perioperative Nurses, Incorporated ("PNI") to determine my fitness for employment by PNI for the purpose of determining the presence in my system of alcohol, illegal drugs, Controlled Substances, or other substances prohibited by the Drug and Alcohol Abuse Policy of PNI.

I understand that the drug screen will be administered by a physician or laboratory facility selected by PNI and will be done at PNI's expense. I agree to go immediately to the physician or laboratory facility selected by PNI, or at the time designated by PNI, to undergo the drug screen. I consent to the disclosure of the results of the drug screen to PNI and to any client of PNI to whom I am referred for work. I understand that a positive test result will cause me to be considered "under the influence" of that substance and will disqualify me for employment by PNI. I have not and will not make any attempt to adulterate drug screen specimens or falsify test results. A "positive test result" is defined as the level of a particular substance designated by the particular physician or laboratory facility selected by PNI to do the drug screen.

Date

Signature of Employee

Employee's Printed Name

AUTHORIZATION

I acknowledge that Perioperative Nurses, Inc. [“PNI”] has clearly and conspicuously disclosed to me, in writing, that it may procure, or cause to be procured, one or more consumer reports or investigate consumer reports, on me for employment purposes or other lawful purposes. I hereby authorize PNI to procure, or to cause to be procured one or more consumer reports or investigate consumer reports on me for employment purposes or other lawful purposes.

I further authorize PNI to disclose to and discuss with any of its clients, to whom I am referred to be considered for work or for whom I actually perform work, on a “need to know” basis only, information obtained about me pursuant to this authorization.

I understand the term “consumer” is defined by the Fair Credit Reporting Act to include an individual.

I understand the term “consumer report” is generally defined by the Fair Credit Reporting Act to include any written, oral, or other communication of any information by a consumer reporting agency bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing eligibility for employment purposes.

I understand the term “consumer report” is generally defined by the Fair Credit Reporting Act to include any written, oral, or other communication of any information by a consumer reporting agency bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing eligibility for employment purposes.

The term “ investigative consumer report” is generally defined by the Fair Credit Reporting Act to include a consumer report or portion thereof in which information on a consumer’s character, general reputation, personal characteristics, or mode of living is obtained through personal interviews.

I understand the term “employment purposes” is defined by the Fair Credit Reporting Act to include the purposes of evaluating a consumer for employment, promotion, reassignment or retention as an employee.

Date

Signature

Printed Name

Date of Birth (for purposes of obtaining consumer report or investigative consumer report only)

Social Security Number

FAIR CREDIT REPORTING ACT DISCLOSURE

Perioperative Nurses, Inc. ["PNI"] hereby discloses that, after it receives appropriate authorization, PNI may procure, or cause to be procured, one or more consumer reports and/or investigative consumer reports pertaining to the person signing below, for employment purposes or other lawful purposes.

If the person signing below makes a written request to PNI within a reasonable period of time after receipt of this Disclosure, PNI will make a complete and accurate disclosure of the nature and scope of the investigation requested.

The term "consumer" is defined by the Fair Credit Reporting Act to include an individual.

The term "consumer report" is generally defined by the Fair Credit Reporting Act to include any written, oral, or other communication of any information by a consumer reporting agency bearing on a consumer's credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing eligibility for employment purposes.

The term "investigative consumer report" is generally defined by the Fair Credit Reporting Act to include a consumer report or portion thereof in which information on a consumer's character, general reputation, personal characteristics, or mode of living is obtained through personal interviews.

The term "employment purposes" is defined by the Fair Credit Reporting Act to include the purpose of evaluating a consumer for employment, promotion, reassignment or retention as an employee.

I HEREBY ACKNOWLEDGE THAT I HAVE READ AND RECEIVED DELIVERY OF THE ABOVE DISCLOSURE UNDER THE FAIR CREDIT REPORTING ACT. I ACKNOWLEDGE THAT, ATTACHED TO THIS DISCLOSURE, IS A COPY OF THE FEDERAL TRADE COMMISSION’S SUMMARY OF RIGHTS UNDER THE FAIR CREDIT REPORTING ACT.

Date

Signature

Printed Name