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Part Time Mammography Tech- Elmore Community Hospital

Radiology Department Elmore Community Hospital

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Monday through Wednesday 8a-2p

Salary negotiable

Job Application

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Step 1 of 10 - Contact Information

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Name*

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Shifts*

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Night

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Rotating

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Full-Time

Part-Time

Temporary

SUPP/PRN

Willing to work holidays?*

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No

Willing to work weekends?*

Yes

No

Date you can begin?*

MM slash DD slash YYYY

Are you legally able to work for all employers in the United States?*

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No

Highest Education Level Completed*

High School

High School Name*

High School City*

High School State*

State

High School Dates Attended*

Did you graduate?*

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Diploma or Degree Received?*

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College

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Second College

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Third College

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Graduate School

Did you attend graduate school?*

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Grad School: Name*

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Grad School: Did you graduate?*

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Grad School: Diploma or Degree Received?*

Yes

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Grad School: Courses or Major*

Graduate hours*

Nursing School

Did you attend nursing school?*

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Nursing School: Did you graduate?*

Yes

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Nursing School: Diploma or Degree Received?*

Yes

No

Nursing School: Courses or Major*

Other Education

Any other school or training?*

Yes

No

Other: Name*

Other: City*

Other: State*

State

Other: Dates Attended*

Certification / Registration 1

Expiration Date 1

Certification / Registration 2

Expiration Date 2

Name of professional or trade organizations to which you belong

Community Hospital

Have you previously worked at Elmore Community or Lake Martin Community Hospital?*

Yes

No

When?*

If employed under a name different from above ( maiden name, nickname, ect. ) Please list*

Do you have any friends and/or relatives employed at Elmore Community or Lake Martin Community Hospital?*

Yes

No

Name 1*

Relationship 1*

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Other

Have you ever been convicted of a felony?*

Yes

No

Please Explain:*

U.S. Military

Are you a veteran?*

Yes

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Dates of Service*

Type of Duty*

Service School or Special Training Received (When and What?)*

Current / Most Recent Employer

Employer 1: Dates of Employment*

Employer 1: Starting Salary*

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Employer 1: May we contact this employer?*

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Second Previous Employer

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Employer 3: Job Duties*

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Employer 3: Supervisor's Name*

Employer 3: Supervisor's Title*

Employer 3: Reason for Leaving*

Employer 3: May we contact this employer?*

Yes

No

Why?*

Office Equipment

Multi-Line Phone

Copy Machine

10-Key Calculator

Fax Machine

Filing Alphabetical

Filing Numerical

Data Entry

Medical Transcription

Medical Terminology

ICD-9-CM Coding

Hospital Housekeeping

Institutional Food Service

Inventory Control

Professional Floor Care

Typewriter:

WPM:*

Computer Software

Word

Excel

dBase

Windows

Microsoft Office

Other Software:

Specify:*

Operating Systems

Windows for Workgroups

Microsoft NT

DOS

Unix

Novell

Other OS

Networking

Programming:

What programing languages?*

Miscellaneous Others:

General Clinical Skills

Quality Management

Staff

Patient

Student/Preceptor

IV Therapy

Venipuncture

Adult

Pediatric

Newborn

Patient Chart/Documentation

Vital Signs

Cardiac Monitoring

EKG

Nursing Skills

Central Sterile

Emergency

Endoscopy/OP Surgery

Intensive Care

SICU/CCU

Long-term Care

Medical/Surgical

OB/GYN/Neonatal/NICU

Oncology

Orthopedic/Neuro

Pediatrics

Psychiatric

Recovery (PACU)

Surgery

Telemetry

Laboratory Skills

Blood Bank

Chemistry

Cytology

Hematology

Histology

Microbiology

GXT9 (Graded Exercise Test)

STAT Lab

Urinalysis/Coagulation

Lab Equip./Instruments

Laboratory Testing,

Please list types of lab equipment, lab testing, and specimen analysis

Radiology Skills

CT

Mammography

MRI

Specimen Analysis

Nuclear Medicine

Ultrasound

Pharmacy Skills

IV Admixtures/Piggybacks/Syringes/Chemo

Patient Nutrition Support

Patient Discharge Consults

Automated Dispensing Equipment

Medication Dispensing

Oral/Liquid Medication Repacking Equip.

Describe nutrition support, IV, or repacking experience:

CAPTCHA

Please Read Carefully

I authorize any employer, school, or person named by me to release any information regarding me or my employment. I hereby release said individuals or organizations from liability for any damage for issuing such information. I certify that the answers given by me to the foregoing questions and statements are true and correct. Further,. any falsification, omission, or misrepresentation of information supplied by me, either orally or on any company document, will be sufficient cause for elimination from continued employment. I understand that neither this document nor any offer of employment from the employer constitutes an employment contract. Furthermore, I understand that any employment is “at will”, which means that either I or Elmore Community Hospital or Lake Martin Community Hospital may terminate my employment at any time with or without cause, reason, or notice. No manager or representative of Elmore Community Hospital or Lake Martin Community Hospital has any authority to enter into an agreement of employment for any specified length of time. In making this application for employment, I agree to submit to a post-offer pre-employment drug and health screen. Should the results of this be unsatisfactory in the judgement of Elmore Community Hospital or Lake Martin Community Hospital, the job offer will be withdrawn. If offered employment, Elmore Community Hospital and/or Lake Martin Community Hospital will be required to verify my identity and eligibility to work in the United States of America, in accordance with the Immigration Reform and Control Act. I understand that documents to verify my identity and eligibility for employment may be submitted in accor dance with regulations of the US Immigration and Naturalization Service. Submitting this information is an acknowledgement that I have read and understand this document. Elmore Community Hospital and/or Lake Martin Community Hospital is an equal opportunity employer. Elmore Community Hospital and/or Lake Martin Community Hospital considers applicants for all positions without regard to race, color, religion, sex, national origin, marital or veteran status, the presence of disability, or any other legally protected status.

Name

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(334) 567-4311 - 500 Hospital Dr, Wetumpka, AL 36092

(334) 567-4311

500 Hospital Dr,Wetumpka, AL 36092

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