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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.

Perioperative Nurses, Inc.

Surgical Technologist 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 Surgical Technologist are obligated to follow all the policies and procedures of the company, as well as those that are adhered to by Surgical Techs in each facility.

II. Minimum Experience Qualifications

Must have a minimum of two years current (within two years) experience as a Surgical Technologist in the operating room and maintain current proof of CPR training. Certification as an S.T. preferred.

III. Organizational Status

Reports directly to the PNI‘s 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/ Assistant Nurse Manager.

IV. Position Summary

Coordinate with the surgical team in the provision of patient care through preparation of instruments, equipment and by assisting the surgeon(s) during the surgical intervention.

V. Essential Job Functions

1. Reports for duty promptly at assigned time and wearing appropriate OR attire.

2. Confidently assume the scrub role function when caring for the surgical patient in a single OR unit.     Heavy

3. Works with the circulating nurse in administering the plan of care by following procedural standards and adhering to aseptic techniques.

4. Anticipates and provides for provides fro physician’s needs during the surgical intervention.

5. Effective skillful and harmonious communications (both oral and written) and good listening skills.

6. Uses professional judgment and decision making when assisting in the implementation of the plan of care.

7. Follows principles of sterile technique.

8. Assists, as required, in preparation of operating room ensuring necessary supplies and equipment are available.

9. Good attendance and dependability.

10. Bending, lifting, stooping, pushing, pulling and stretching to position and/or move patients or equipment and manual dexterity.     Heavy

11. Regular walking and standing.     Heavy

13. Compliance with lawful policies of PNI and its clients on whose premises the individual works.

14. Complies with applicable standard of care for work.

15. Complies with lawful requests of any job description of hospital’s client on whose premises the individual works.

16. Prepares supplies, instruments and equipment according to procedure, surgeon’s preference and patient’s age-specific needs and maintains a correct count.     Heavy

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

I have received and reviewed the above job description.

Signature   Date  

SCRUB TECHNICIAN

SCREENING TEST

NAME DATE SCORE

Please, circle the letter of the correct answer.

1. The complete destruction of all living organisms is known as: Ans.

1. disinfection
2. sterilization
3. pasteurization
4. bactericidal

2. Which of the following methods of sterilization is the most practical and inexpensive technique to sterilize objects that can withstand high temperature? Ans.

1. dry heat
2. radiation
3. moist heat under pressure
4. ethylene oxide(ETO)

3. What is the correct procedure to follow when a sterile metal graduate is opened and the scrub person notices water droplets on the inside? Ans.

1. Discard the pitcher because it is considered contaminated.
2. Use it because the droplets are sterile.
3. Use it, but dry it out first, then discard the towel.
4. Let the container air dry and use it.

4. What quality control device ensures the absence of all living organisms? Ans.

1. process monitors (indicators)
2. biologic monitors
3. Bowie-dick test
4. chemical indicator

5. Reduced blood flow to an area is known as: Ans.

1. hemostasis
2. infarction
3. ischemia
4. hemorrhage

6. The acronym MAC stands for: Ans.

1. mixed anesthesia
2. manipulated anesthesia comfort
3. monitored anesthesia care
4. most always can

7. Dark blood in the operative field is a sign of possible: Ans.

1. rigid chest
2. hypoxia
3. hypertension
4. hypothermia

8. You are asked to flash sterilize the instrument set used on the last case for your next procedure. After appropriate cleaning you would flash the set at: Ans.

1. 3 minutes/ 270°F
2. 10 minutes/ 270°F
3. 8 minutes/ 290°F
4. 30 minutes/ 270°F

9. Another name for a bunion is Ans.

1. hague deformity
2. hallux valgus
3. hammer toe
4. hallux rigidus

10. The symbol for sodium chloride (saline) is Ans.

1. schl
2. H2O
3. FE
4. NaCl

11. Which of the following terms does not permit a person to excuse an error but to admit and rectify one immediately? Ans.

1. Golden Rule
2. Respondent Superior
3. Universal Precautions
4. Surgical Conscience

12. For aseptic purposes, covering a sterile table for later use Ans.

1. is permissible for up to 1 hour before the procedure.
2. is permissible for up to 2 hours before the procedure.
3. is permissible only if there is an emergency.
4. is not recommended.

13. The purpose of the surgical hand scrub is Ans.

1. to decrease the number or resident microorganisms.
2. to keep the number of microorganisms minimal during the operative procedure.
3. to reduce the hazard of microbial contamination of the operative wound by skin flora.
4. all of the above

14. The patient is never positioned until the Ans.

1. surgeon gives his or her permission.
2. anesthesia gives his or her permission.
3. scrub person is in the room.
4. circulator has finished all the prepatory duties.

15. To be effective in killing microorganisms, steam sterilization requires specific Ans.

1. temperatures and pressures
2. temperatures and times
3. times and pressures
4. time and moisture

16. What is the first step to take for an incorrect count? Ans.

1. notify surgeon
2. call for x-ray
3. repeat count immediately
4. nothing, because there is another count to be done

17. What type of irrigating solution is used to cleanse the inside of an artery? Ans.

1. protamine sulfate
2. thrombin
3. heparanized saline
4. ringer’s lactate

18. In an instrument count, Ans.

1. pre-counted sets eliminate the need for pre-case counts
2. all instruments and parts must be counted
3. large bulky instruments need not be counted
4. count only instruments that will be used.

19. Which of the following sutures is a polyester fiber suture? Ans.

1. vicryl
2. dexon
3. ethibond
4. chromic

20. What is the PRIMARY responsibility of the scrub person if a cardiac arrest occurs during surgery? Ans.

1. suction the patient
2. protect the sterile field
3. maintain a clear airway
4. start intravenous infusion

21. What type of solution would most often be used to fill a breast implant? Ans.

1. ringer’s lactate
2. normal saline irrigation
3. injectable saline
4. glycine irrigation

22. The gallbladder is located nearest to: Ans.

1. stomach
2. spleen
3. liver
4. pancreas

23. Which article must be kept functioning until the patient leaves the room? Ans.

1. electrosurgical unit
2. suction
3. surgical lights
4. x-ray view box

24. Which of the following must be included in the set up for an open reduction internal fixation of a fractured femur? Ans.

1. mallet
2. osteotome
3. bone holder
4. poole suction tip

25. Which items are needed for a laparoscopy? Ans.

1. light cord and scope
2. camera
3. Richards
4. both a and b

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.

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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