staffing request form Step 1 of 8 - Company Information 12% 1. Company InformationCompany Name(Required)Point of Contact Name(Required)POC TitleEmail Address(Required) Phone Number(Required)Contract NumberContract Type(Required)Select Contract TypeFederalStateCommercialNAIs this SCA?(Required)Select SCA OptionYesNoNAAgencySCA Labor CategoryHealth & Welfare Rate 2. Position TypePosition Type(Required)Select Position TypeNursingAllied HealthTherapy & RehabImaging & DiagnosticsLaboratoryPharmacyAdministrative / ClericalIT / Cyber / Health TechPhysician / APPOtherPlease enter other position type. 3. Position SpecialtyA. If Position Type is NursingNursing SpecialtyCRNANurse-MidwifePMHNPFNPCNSNurse EducatorInformatics NurseOncology NurseOR NurseDialysis NurseInfection Control NurseNurse ResearcherTrauma NurseNeonatal NurseGeriatric NurseAcute Care NursePublic Health NurseNurse AdvocatePediatric NurseOtherPlease enter other nursing specialty.Shift Type(Required)DayNightRotatingNACertifications(Required)Years of Experience(Required)0–12-34-67+NAB. If Position Type is Allied HealthAllied Health SpecialtyRespiratory TherapistSurgical TechnologistPharmacy TechnicianMedical AssistantSocial WorkerDietitianBehavioral Health TechPatient Care TechSterile Processing TechOccupational Health & Safety TechnicianOtherPlease enter other Allied Health specialty.C. If Position Type is Therapy & RehabTherapy & Rehab SpecialtyPhysical Therapist (PT)Occupational Therapist (OT)Speech-Language Pathologist (SLP)Physical Therapist Assistant (PTA)Certified Occupational Therapy Assistant (COTA)OtherPlease enter other Therapy & Rehab specialty.D. If Position Type is Imaging & DiagnosticsImaging & Diagnostics SpecialtyRadiologic TechnologistDiagnostic Medical SonographerCardiovascular TechnologistNuclear Medicine TechnologistSpecial Procedures Technologist (CT/MRI)Mammography TechnologistUltrasound TechnologistEcho Technologist (Cardiac Sonographer)OtherPlease enter other Imaging & Diagnostics specialty.E. If Position Type is LaboratoryLaboratory SpecialtyMedical Laboratory Technician (MLT)Medical Technologist (MT / MLS)Lead Medical TechnologistChief Medical TechnologistPhlebotomistOtherPlease enter other Laboratory specialty.F. If Position Type is PharmacyPharmacy SpecialtyPharmacy TechnicianPharmacistOtherPlease enter other Pharmacy specialty.G. If Position Type is Administrative / ClericalAdministrative / Clerical SpecialtySchedulerCall Center / Surge SupportBilling & Coding SpecialistHR AssistantProgram ManagerProject CoordinatorExecutive AssistantOtherPlease enter other Administrative / Clerical specialty.H. If Position Type is IT / Cyber / Health TechIT / Cyber / Health Tech SpecialtyCybersecurity AnalystNetwork EngineerHelp Desk TechnicianEHR SpecialistInformatics AnalystSystems AdministratorOtherPlease enter other IT / Cyber / Health Tech specialty.I. If Position Type is Physician / APPPhysician / APP SpecialtyPhysicianPhysician Assistant (PA)Nurse Practitioner (NP)Specialist PhysicianOtherPlease enter other Physician / APP specialty.Please enter physician specialty. 4. Position DetailsJob TitleUpload Job DescriptionAccepted file types: pdf, jpg, doc, docx, png, Max. file size: 1 GB. Years of Experience0–12-34-67+NACertifications RequiredWork LocationOnsiteHybridRemoteNACity / State / ZipStart Date MM slash DD slash YYYY Number of Positions NeededUrgency LevelImmediate 24–72 hrsHigh Priority 1–2 weeksStandard 30 days 5. Employment Type (Permanent or Contract)Employment Type(Required)Select Employment TypePermanentContractNASalary RangeRelocation Assistance Available?YesNoNAContract Length30 days60 days90 days6 months1 yearMulti-yearNAOvertime Authorized?YesNoNAShift Differential?YesNoNA 6. Security Clearance RequirementsSecurity Clearance Requirements?(Required)Select Security Clearance RequirementYesNoNAClearance Level Options:Public Trust (Suitability):Public Trust – Tier 1Public Trust – Tier 2Public Trust – Tier 4National Security Clearances:ConfidentialSecretTop Secret (TS)Top Secret / SCI (TS/SCI)SCI Compartments SI TK HCS NA Other Please specify other SCI compartmentDOE Clearances:Q ClearanceL ClearanceNAOther:OtherNAPlease enter other clearance levelPolygraph Required?NoneCI PolyFull Scope/LifestyleNAClearance Must Be Active?YesNoNASponsorship Available?YesNoNA 7. Pay and Billing InformationPay Rate (if known)Bill Rate (if known)Rate Negotiable?YesNoNA 8. Additional NotesAdditional Comments / Instructions
