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Facility's Needs Form

* Required Information

Facility's Information

* Organization:

* Facility:

* Administrator / Contact Name:

* Title:

* Street Address:

* City:

* State:

* Zip Code:

* Telephone Number:

* Fax Number:

* Email Address:

Facility's Needs

Requested Position:

Start Date:

Estimated Assignment Length:

Shift Desired

Chronic/Acute:

Unit Beds/Stations:

Nurse to Patient Ratio:

PCT to Nurse Ratio:

Dialysis Machine Used:

Special Requirements/Training

* How did you hear about QTS?

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