The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

ckS6MBZUKLWPVSJfoGpzKQnLojZGvVBREXnxtyNzT9t3yVtNm

COVID Response: Temporary Healthcare Workers Needed

The Minnesota Department of Health (MDH) continues to support Long-term Care (LTC) facilities (Skilled Nursing and Assisted Living) experiencing staffing shortages due to COVID-19.

The following form requests information from licensed and unlicensed healthcare workers (RNs, LPNs, Nursing Assistants) willing to assist long-term care providers experiencing a staffing shortage due to a COVID-19 outbreak in their facility. Your information will be transferred to our Aladtec system (LTC COVID-19 response supplemental staffing database) to provide temporary support.

Please complete the information below. On a weekly basis information is compiled and submitted to Aladtec for account creation. Additional information regarding next steps will be communicated to you shortly thereafter.

Sent to Aladtec

New Request

Reviewed, sent to Aladtec

Reviewed, not sent to Aladtec

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First Name

* must provide value

Last Name

* must provide value

Phone number

* must provide value

Address

County

* must provide value

Credentials

* must provide value

Registered Nurse Clinical Role

Nursing Assistant Clinical Role

Licensed Practical Nurse Clinical Role

Housekeeping NON-Clinical Role

Dining and Dietary Services NON-Clinical Role

Activities Assistant NON-Clinical Role

Multipurpose Assistant NON-Clinical Role

Credentials

* must provide value

Registered Nurse

Nursing Assistant

Home Health Aide

Licensed Practical Nurse

Trained Medication Assistant

Emergency Medical Technician

Other

What is your current MN clinical license or certificate number?

LPN/RN clinical license infomation can be found at:

https://mbn.hlb.state.mn.us/#/services/onlineEntitySearch

CNA/NA certification information can be found at:

https://narlookup.web.health.state.mn.us/

If you don't have a current license, you can apply in a non-clinical position. DO NOT enter your social security number.

* must provide value

Other credential(s)

Work Availability

Weekday days

Weekday evenings

Weekday nights

Weekend days

Weekend evenings

Weekend nights

What race do you most identify with? Check all that apply.

* must provide value

White/Caucasian

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Prefer not to answer

What ethnicity do you most identify with?

* must provide value

Hispanic/Latino

Non Hispanic/Latino

Prefer not to answer

How far are you willing to travel from your home residence?

NOTE: No paid travel expenses available

Any long-term care or assisted living experience?

* must provide value

Yes

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Are you willing to work with COVID-19 positive residents?

* must provide value

Yes

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Provide any additional comments (e.g. any limitations to your ability to work)?

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How did you find out about Aladtec?

* must provide value

Expand

Date Submitted

Y-M-D

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