Request Staff Staff Request FormFacility InformationFacility Type– Select –HospitalAmbulatory Surgery Center (ASC)Outpatient ClinicLong-Term Care FacilitySterile Processing Department (Standalone)OtherContact InformationPlease provide the contact details of the individual authorized to request staffing services. Our staffing coordination team will use this information for follow-up regarding assignment details and credentialing requirements.Contact Person First NameContact Person Last NameTitle / Role– Select –DirectorManagerSupervisorHR CoordinatorMSP CoordinatorOtherEmail AddressPhone/MobileProgram Type (Optional)Indicate whether this request is being submitted through a Managed Service Provider (MSP) or Vendor Management System (VMS).Is this request submitted through an MSP or VMS program? Yes NoMSP / VMS Program Name– Select Program –Aya Healthcare MSPHealthTrust Workforce SolutionsAMN MSPCross Country MSPShiftWiseFieldglassMedefisOtherEnter MSP / VMS Name (if Other selected)Assignment DetailsProvide details about the requested staffing position and assignment requirements.Position RequestedSelect applicableSterile Processing Technician (SPD)Registered Nurse (RN)Respiratory TherapistRadiology TechnologistLicensed Practical Nurse (LPN)Lead Sterile Processing TechnicianSurgical TechnologistAnesthesia TechnologistMedical AssistantEndoscopy TechnicianOtherSpecify Position (if Other selected)Target Start DateNumber of Professionals NeededShift Type– Select Shift Type –Day ShiftEvening ShiftNight ShiftRotatingWeekend OnlyFlexibleOtherSpecify Shift Type (if Other selected)Assignment Duration– Select Duration –Per Diem2 Weeks4 Weeks8 Weeks13 Weeks26 WeeksTemp-to-HireDirect HireOtherUrgency Level– Select Urgency –Immediate (within 48 hours)Urgent (within 1 week)Standard (within 2–3 weeks)Future PlanningSchedule Details / NotesCredential RequirementsSelect any required certifications, licenses, screenings, or onboarding requirements for this assignment.Required Credentials / Compliance Items CRCST Required CSPDT Accepted CBSPD Accepted BLS Required ACLS Required NY State License Required Travel Experience Required Background Check Required Drug Screen Required Immunization Records Required Facility Orientation Required Fit Testing Required OtherSpecify Additional Credential Requirement (if Other selected)Department Requesting Staff– Select –Sterile Processing DepartmentOperating RoomEndoscopyRadiologyRespiratory TherapyMedical-Surgical UnitICUEmergency DepartmentLabour & Delivery UnitOtherSpecial Equipment / System Experience (Optional)Compliance ConfirmationPlease confirm authorization to submit this staffing request.Checkbox Field I confirm I am authorized to request staffing services on behalf of this facility. Placement availability is subject to credential verification, facility approval, and regulatory compliance.Submit Staffing Request
