Find top talent with Merkins Staffing and Placement Agency, ensuring the perfect fit for your team's needs.

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Services
Jobs
Contact
Blog
Providers

Provider Assessment Form

Streamline your hiring process with our comprehensive assessment form tailored for staffing providers.

Business Name*

Provider first & Last name

Your Business email*

Business Phone*

Business Address*

Years of Experience

0-2

2-4

4-8

10+

Facilities*

LTC

Assisted Living

Hospital

Private Home

Adult Family Home (AFH)

Other

Populations*

Elderly

Pediatric

Adult

Dementia

Developmental

Crisis Care

Other

Skills*

Vitals

Meds

Wound Care

Catheters

G-Tubes

Transfers

Baths

EMR

Behavior Mgmt

Emergencies

References (2 Supervisors/Colleagues)*

Background check ( Have you been convicted with crime?)*

Yes

If Yes, Please explain*

Disciplinary Action?*

Yes

If Yes, please explain*

(Consent) I certify that all info is true and authorize verification and background checks.*

Yes

Provider Assessment Form

Streamline your hiring process with our comprehensive assessment form for staffing and placement providers.

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Easy Submission Form

Submit your assessments easily and efficiently to ensure a smooth staffing and placement experience.

Comprehensive Evaluation Tool

Utilize our evaluation tool to assess provider qualifications and enhance your staffing decisions effectively.

Care

Dedicated staffing for your medical facility needs.

Support

Trust

info@merkinplacement.com

+1206-304-0934

+1206-966-2623

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