Let's start with some basic contact info and so we can keep in touch!
Todays Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Time
Hour Minutes
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PM
AM/PM Option
I am a
RN
LPN
CNA
CMA
EMT
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Name
First Name
Middle Name
Last Name
Email
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A link will be emailed to you so you can resume this form at any time.
Mobile Number
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Please enter a valid phone number.
Format: (000) 000-0000.
I agree to receive employment-related SMS/text messages from JT Solutions Group LLC, including onboarding, credentialing, scheduling, shift opportunities, shift confirmations, reminders, and other employment communications. Message frequency may vary. Message and data rates may apply. Reply HELP for help and STOP to opt out.
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I consent to receive employment-related SMS/text messages.
Cell Phone Carrier
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Verizon
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Birth Date
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Required for Paychex payroll setup
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Lets Build Your Profile!
We create a profile for you that contains all the information a hospital needs to make the decision to offer you a position. The more complete the profile the more money we can qualify you for. You can always save and continue any question from any point in this app. The profile is made up of documents that prove your qualifications. You can upload them, or take pictures of them with your phone. If you use an iphone, turn off the LIVE feature (we dont need the animation). If you don't have this information, just skip the question and you can come back to it at a later time. This is actually pretty easy, you'll see. Lets get started.
Drivers License - Camera or File Upload
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RN, LPN, CNA License - File Upload
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License State
License Number
Expiration Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
BLS or ACLS - File Upload
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BLS or ACLS Expiration Date
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Month
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Day
Year
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Date
Recent Drug Screening - File Upload
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Date Of Drug Screening
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Within the last 12 months. If you dont have one we can scheule one for you.
I don't have this... No Problem! We can email or text you an authorization code that can be used at any Concentra location to obtain these tests at no cost to you. Please check all that apply
I need a TSPOT TB Test
I need a Drug Screening
I need a Physical
Other
Do you have a criminal record that may affect employment?
Yes
No
Background Check - File Upload
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Date of Background Check
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I don't have this...No Problem!
The easiest way to get one is from the PA state police for $22. Here is the link. https://epatch.state.pa.us/
Child Abuse Clearance - File Upload
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I don't have this...No Problem!
The easiest way to get one is from the PA Child Welfarfe portal for $13. Here is the link. https://www.compass.state.pa.us/cwis/public/home
Resume or Work History - File Upload
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Health Forms
Recent Physical - Camera or File Upload
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TB Test Results - Camera or File Upload
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Date of TB Test
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Covid Vaccination Card - Camera or File Upload
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Date of Last Covid Vaccine
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Documentation of Flu Vaccine - Camera or File Upload
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Date of last flu vaccine
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I don't have these. Thats OK, we can Email or Text you an Authorization code that can be used at any Concentra Location to obtain a TB Test at no cost to you. Please check all that apply
I need a TSPOT TB Test
I need a Drug Screening
I need a Physical
Other
I am allergic to Latex:
YES
NO
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Hepatitis B Vaccine Declination Statement
I understand that due to my educational and or vocational exposure to blood or other potentially infectious bodily fluids I may be at risk of acquiring hepatitis B virus (HBV). I have been given the opportunity to be vaccinated with hepatitis B vaccine at my own expense.
I have proof of immunity by a positive anti-HBs blood titer, formerly known as the hepatitis B surface antibody (HBSAB).Please indicate which of the following scenarios apply:
Please schedule me to receive the hepatitis B vaccine series.
I am process of getting the hepatitis B series.
I do not want the vaccine.
I decline hepatitis B vaccination at this time as I have proof of immunity by a positive anti-HBs blood titer, formerly known as the hepatitis B surface antibody (HBSAB). I have attempted to find documentation of my prior hepatitis B vaccinations. However, I am unable to find these records at this time.
I have proof of immunity by a positive anti-HBs blood titer, formerly known as the hepatitis B surface antibody (HBSAB).
Hep B Documentation Or Declination
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This statement is not a waiver;
• Employees can request and receive the hepatitis B vaccination at a later date if they remain occupationally at risk for hepatitis B
An employer can not require:
• Employees to waive liability in order to receive the vaccine• Participation in pre-screening as a prerequisite for receiving the vaccine.
Signature
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Almost Done... Lets get you Paid !
Here we will gather everything you will need to get paid quickly.
Date Available
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Preferred
Day
Evening
Night
Shift Type
Per Diem
3 month short term contract
6 month contract
Please use the space below to let us know you preferences in terms of Facility, Commute, Restrictions, Pay, Etc.
Social Security Number
*
Required for Paychex payroll setup. Used only for payroll.
Filing Type
Single or Married filing separately
Married filing jointly or Qualifying widow(er)
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
How many withholdings (dependents)
Signature
Bank Name
Routing Number
Account Number
Drivers License
Account Type
Checking
Saving
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