Job Order Name* First Last Title*Organization*Email* Phone*Company Website*Is your opening Interim or Direct-Hire?* Interim Direct-Hire In which specialty area is your job opening?* Infection Prevention & Control: Hospital Epidemiology Health Quality Assurance: Accreditation, Compliance, Performance Improvement, Patient Safety, Risk Management Clinical Nurse Leadership: VP / Chief Nursing Officer, Departmental Director Healthcare Finance: Revenue Cycle Healthcare IT: Health Information Management (HIM), Health Information Systems Administration / Operations / Support: Medical Staff Services, Case Management Pharmacy Leadership Position RequirementsWhat is the formal title of this position?What is the title of the person the position reports to?Is this a lead position. team member or sole practitioner role?SelectLeadTeam MemberSolo PractitionerIf this is not a Sole Practitioner role; how many Infection Preventionists in the department, including this position?How long has the position been vacant?Will the Preventionist be responsible for Infection Prevention at any facilities / clinics outside of the main hospital?Will the Preventionist also be responsible for Employee Health functions?SelectYesNoEducation & CertificationBachelor's Degree:SelectPreferredRequiredNot RequiredMaster's Degree:SelectPreferredRequiredNot RequiredIs a CIC (Certification in Infection Prevention) preferred or required?SelectPreferredRequiredNot RequiredIs an RN (Registered Nurse) required?SelectYesNoWould you also consider a qualified MT or MPH candidate with a CIC certification and acute care infection prevention experience?SelectYesNoFacility | CompensationWhat software package is being used for surveillance data (AICE, MedMined, TheraDoc, SafetySurveillor, MS Access, EXCEL, etc.).If The Joint Commission accredited, when was your last survey?Total licensed beds?What is your average daily census?Are you a for-profit or not-for-profit facility?SelectProfitNon-ProfitDoes the department have designated or shared Administrative support?SelectDesignatedSharedHourly or exempt position?SelectHourlyExemptWhat is the hourly/salary range for this position (low – high) and where would you prefer it come in?LowHighPreferred AmountDo you offer relocation assistance?SelectYesNoIf Yes, is it calculated case-by-case or a flat rate?SelectCase-By-CaseFlat RateOtherAnything about the facility, management, ownership, staff, position itself or challenges ahead that will help us identify the most ideal candidate (positives, negatives, selling points)?Position RequirementsWhat is the formal title of this position?What is the title of the person the position reports to?How Many FTEs report to this position?How long has the position been vacant?Will this position be responsible for any facilities / clinics outside of the main hospital?Education & CertificationBachelor's Degree:SelectPreferredRequiredNot RequiredMaster's Degree:SelectPreferredRequiredNot RequiredCPHQ (Certified Professional in Healthcare Quality)?SelectPreferredRequiredNot RequiredIs an RN (Registered Nurse) required?SelectYesNoFacility | CompensationIf Joint Commission Accredited, when was your last survey?Total licensed beds?What is your average daily census?Are you a not-for-profit or for-profit facility?SelectFor-ProfitNon-ProfitDoes the department have designated or shared Administrative support?SelectDesignatedSharedHourly or exempt position?SelectHourlyExemptWhat is the hourly/salary range for this position (low – high) and where would you prefer it come in?LowHighPreferred AmountDo you offer relocation assistance?SelectYesNoIf Yes, is it calculated case-by-case or a flat rate?SelectCase-by-CaseFlat RateOtherAnything about the facility, management, ownership, staff, position itself or challenges ahead that will help us identify the most ideal candidate (positives, negatives, selling points)?Position RequirementsWhat is the formal title of this position?What is the title of the person the position reports to?How Many FTEs report to this position?How long has the position been vacant?When do you plan to fill this position?Will this position be responsible for any facilities / clinics outside of the main hospital?Summary of responsibilities:(quick bullets, cut and paste job description or provide a link to the job webpage)Technology Requirements:Education, Certification, LicenseAssociates Degree:SelectPreferredRequiredBachelor's Degree:SelectPreferredRequiredNot-RequiredMaster's Degree:SelectPreferredRequiredNot-RequiredList Required Certifications:List Preferred Certifications:List Required LicenseList Preferred LicenseFacility | CompensationIf Joint Commission Accredited, when was your last survey?Total licensed beds?What is your average daily census?Are you a not-for-profit or for-profit facility?SelectFor-ProfitNon-ProfitHourly or exempt position?SelectHourlyExemptWhat is the hourly/salary range for this position (low – high) and where would you prefer it come in?LowHighPreferred AmountDo you offer relocation assistance?SelectYesNoIf Yes, is it calculated case-by-case or a flat rate?SelectCase-by-CaseFlat-RateOtherAnything about the facility, management, ownership, staff, position itself or challenges ahead that will help us identify the most ideal candidate (positives, negatives, selling points)?Interim Assignment Questionnaire - IP1. What is the title for the position/opening?2. What date would you ideally like an interim to begin your assignment? MM slash DD slash YYYY How long do you expect the assignment to last?Choose One1 Month1 - 3 Months3 - 6 Months6 - 9 Months9 - 12 Months12+ Months3. What is the title of the person the Interim position reports to (nursing or quality)?4. Type of position:Choose OneTeam MemberSole PractitionerLeadership Position5. How many Infection Preventionists in the department other than this position?Choose OneSole12345678910+6. Will the Preventionist be responsible for Infection Prevention at any facilities/clinics outside of the main hospital?Choose OneYesNoExplain7. Will the Preventionist also be responsible for Employee Health functions?Choose OneYesNo8. Is a CIC (Certification in Infection Control) preferred or required?Choose OnePreferredRequiredNot-RequiredBachelor'sChoose OnePreferredRequiredNot Required9. Educational Degree:Master'sChoose OnePreferredRequiredNot Required10. Is an RN (Registered Nurse) preferred or required:Choose OnePreferredRequiredWill you consider qualified RN candidates that are not currently licensed in your state, however, that have active licensure in another state or states?Choose OneYesNoIf licensure in your state is required, this may limit the availability of immediate resources for your assignment In lieu of a licensed RN; will you consider an acute care experienced CIC certified MT or MPH Interim?Choose OneYesNo11. What software package is being used for surveillance data? AICE EXCEL MedMined MS Access SafetySurveillor Sentri7 TheraDoc Other Other12. Hospital/facility is accredited by: DNV State The Joint Commission Other OtherWhen was your last survey? MM slash DD slash YYYY 13. What are your total licensed beds?What is your average daily census?14. Does the department have designated or shared administrative support?Choose oneNo SupportDesignatedShared15. Are there any specific areas you are having problems with that the interim Infection Preventionist should focus on initially?Interim Assignment Questionnaire - QA1. What is the title for the position/opening?2. What date would you ideally like an interim to begin your assignment? MM slash DD slash YYYY 3. How long has the position been vacant?4. What is the title of the person the Interim position reports to (nursing or quality)?5. How many FTEs report to this position?6. What department(s) or area(s) will the Interim be responsible for?7. Will this position have responsibility for any facilities/clinics outside of the main hospital?Choose OneYesNoIf Yes, Explain8. Is an RN (Registered Nurse) preferred or required:Choose OnePreferredRequiredNot RequiredWill you consider qualified RN candidates that are not currently licensed in your state, however, that have active licensure in another state or states?Choose OneYesNoIf immediate licensure in your state is required, this may limit the availability of resources for your assignment. 9. Educational Degree: Bachelor'sChoose OnePreferredRequiredNot-RequiredMaster'sChoose OnePreferredRequiredNot-Required10. Is a CPHQ (Certified Professional Healthcare Quality) preferred or required?Choose OnePreferredRequiredNot-Required11. How is your facility accredited? DNV State The Joint Commission Non-accredited Other OtherWhat was the date of the last accreditation survey? MM slash DD slash YYYY 12. Is your facility for-profit or not-for-profit?Choose OneFor-ProfitNon-Profit13. What are your total licensed beds?What is your average daily census?14. Does the department have designated or shared administrative support?Choose OneNo SupportDesignatedShared15. Are there any specific areas you are having problems with that the Galileo Interim should focus on initially?Interim Assignment Questionnaire1. What is the title for the position/opening?2. What date would you ideally like an interim to begin your assignment? MM slash DD slash YYYY How long do you expect the assignment to last?Choose One1 Month1 - 3 Months3 - 6 Months6 - 9 Months9 - 12 Months12+ Months3. How long has the position been vacant?4. How many FTEs report to this position?5. What department(s) or area(s) will the Interim be responsible for?6. Will this position have responsibility for any facilities/clinics outside of the main hospital?Choose OneYesNoIf Yes, Explain7. Is immediate or temporary RN licensure in your state required for this assignment? If yes, this may delay or limit the availability of resources for your assignment.Choose OneYesNo8. Educational Degree: Bachelor'sChoose OnePreferredRequiredNot-RequiredMaster'sChoose OnePreferredRequiredNot-Required9. What certifications are required?10. Minimum number of years required in similar role?Minimum number of years required in management role?Minimum number of years of required hospital experience?11. How is your facility accredited? DNV State The Joint Commission Other OtherWhat was the date of the last accreditation survey? MM slash DD slash YYYY 12. Is your facility for-profit or not-for-profit?Choose OneFor-ProfitNon-For-Profit13. What are your total licensed beds?What is your average daily census?14. Are there any specific areas you are having problems with that the Galileo Interim should focus on initially?Pharmacy LeadershipWhat is the title for the position/opening?Title of the person this position reports to:What date would you ideally like an interim to begin your assignment?MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How long do you expect the assignment to last?Choose One1 Month1-3 Months3-6 Months6-9 Months9-12 MonthsHow long has the position been vacant?How many FTEs report to this position?What department(s) or area(s) will the Interim be responsible for?Will this position have responsibility for any facilities/clinics outside of the main facility?Choose OneYesNoLicensingWhat licensure(s) are required for this position?Is immediate or temporary licensure in your state required for this assignment?Choose OneYesNoCertificationWhat certification(s) are required for this position?Education DegreeBachelor'sChoose OnePreferredRequiredNot RequiredMastor'sChoose OnePreferredRequiredNot RequiredDoctorateChoose OnePreferredRequiredNot RequiredMinimum ExperienceMinimum number of years required in similar role?Minimum number of years of required in hospital environment?Patient VolumeWhat is the approximate number of patients seen for therapeutic services per year?Are there any specific areas you are having problems with that the Galileo Interim should focus on initially?Pharmacy LeadershipWhat is the formula title of this position?What is the title of the person the position reports to?How Many FTEs report to this position?How long has the position been vacant?MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920When do you plan to fill this position?MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Will this position be responsible for any facilities/clinics outside of the main facility? If yes, please explain i.e., number of facilities, distance form the main, etc.Summary of responsibilities:quick bullets, cut and paste job description or provide a link to the job web pageEducation, Certification, LicenseAssociates Degree:Choose OnePreferredRequiredNot RequiredBachelor's Degree:Choose OnePreferredRequiredNot RequiredMaster's Degree:Choose OnePreferredRequiredNot RequiredDoctorate:Choose OnePreferredRequiredNot RequiredCertification(s) Preferred:Certification(s) Required:License(s) Preferred:License(s) Required:Facility & CompensationEstimated number of patients seen per year?Hourly for exempt position?Choose OneHourlyExemptSalaryWhat is the hourly/salary range for this position (low-high) and where would you prefer it come in? LowHighPreferred AmountRelocationDo you offer relocation assistance?Choose OneYesNoIf Yes, is it calculated case-by-case or a flat rate?Choose OneCase-by-caseFlat rateOther InformationAnything about the facility, management, ownership, staff, position itself or challenges ahead that will help us identify the ideal candidate (positives, negatives, selling points)?
