Hurricane Harvey: Staffing Availability

Houston Area Flooding: Availability to Report to Work

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* 1. General Information

Last, First Name

Employee ID

Title/Role

Facility

Phone: Work

Phone: Personal

Preferred Email

Home Address Street

Home Address City

Home Address Zip Code

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* 2. Are you able to report to your assigned hospital?

Yes

N/A

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* 3. If childcare is a barrier, would you be able to report to work if on-site childcare for children 3 to 13 years of age is available?

Yes

N/A

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* 4. If transportation is a barrier, would you be able to report to work if we provided transportation?

Yes

N/A

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* 5. Please check all locations you are willing to work?

Baylor St. Luke's Medical Center (Houston, TX)

CHI St. Luke's The Woodlands Hospital (The Woodlands, TX)

CHI St. Luke's Lakeside Hospital (The Woodlands, TX)

CHI St. Luke's Springwoods Village Hospital (Spring, TX)

CHI St. Luke's Vintage Hospital (Houston, TX)

CHI St. Luke's Sugar Land Hospital (Sugar Land, TX)

Patients Medical Center (Pasadena, TX)

CHI St. Luke's Brazosport (Lake Jackson, TX)

CHI St. Luke's Memorial Lufkin (Lufkin, TX)

CHI St. Luke's Memorial Livingston (Livingston, TX)

CHI St. Luke's Memorial San Augustine (San Augustine, TX)

CHI St. Joseph Regional Hospital (Bryan, TX)

CHI St. Joseph Grimes Hospital (Navasota, TX)

CHI St. Joseph Bellville Hospital (Bellville, TX)

CHI St. Joseph Madison Hospital (Madisonville, TX)

CHI St. Joseph Burleson Hospital (Caldwell, TX)

Other (please specify)

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* 6. What shifts are you able to work?

Day Shift (7:00am - 3:00pm)

Evening Shift (3:00pm - 11:00pm)

Night Shift (11:00pm - 7:00am)

12 Hour Shift (7:00am - 7:00pm)

12 Hour Shift (7:00pm - 7:00am)

Flexible - Any Shift

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* 7. Are you able to work weekends?

Yes

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* 8. Are you willing to work in another capacity similar to your existing role? (I.E. Administrative Assistant functioning as Unit Secretary)

Yes

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* 9. Are you willing to pick up CHI employees in your area to drive them to work?

Yes

Hurricane Harvey: Staffing Availability

Houston Area Flooding: Availability to Report to Work

Question Title

* 1. General Information

Question Title

* 2. Are you able to report to your assigned hospital?

Question Title

* 3. If childcare is a barrier, would you be able to report to work if on-site childcare for children 3 to 13 years of age is available?

Question Title

* 4. If transportation is a barrier, would you be able to report to work if we provided transportation?

Question Title

* 5. Please check all locations you are willing to work?

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* 6. What shifts are you able to work?

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* 7. Are you able to work weekends?

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* 8. Are you willing to work in another capacity similar to your existing role? (I.E. Administrative Assistant functioning as Unit Secretary)

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* 9. Are you willing to pick up CHI employees in your area to drive them to work?

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* 10. If you answered yes to Q9, do you have a truck or SUV that can safely travel through water?

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* 11. What is your Nursing Specialty?

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* 12. What is your home department/unit?

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* 13. Direct Supervisor/Manager Contact Information