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Facilities

Providing the highest quality and professional services since 1989.

At Dependable Staffing, we are committed to matching you with the most qualified individuals for your company’s needs. Complete the form below with your information to find the right professional today.

Facility Intake Form

Company Name * :

EIN Number * :

Dun & Bradstreet Number :

Authorized Company Representative Name and Title * :

Phone * :

Email * :

Facility Name:

Address:

Phone:

Fax:

Website Address:

Corporate Billing Contact:

Billing Address:

Phone:

Fax:

Email:

Facility Billing Contact:

Billing Address:

Phone:

Fax:

Email:

Director of Nursing:

Phone:

Fax:

Email:

Facility Administrator:

Phone:

Fax:

Email:

Staffing Coordinator:

Phone:

Fax:

Email:

Facility Type (check all that apply) :

Retirement Home

Assisted Living

Memory Care

Nursing Home

Hospital

Psychiatric Facility

Clinic

Adult Family Home

Home Health

Other: _

Nurse Ratio Per Floor:

Aide Ratio Per Floor:

Patient Ratio per Floor:

Shift Start & Stop Hours:

NAC/HHA/MAC

RN/LPN/MT

1st Shift:

1st Shift:

2nd Shift:

2nd Shift:

3rd Shift:

3rd Shift:

12 Hour Shift Start & Stop Times:

Medical Treatment Shift:

Assisted Living Shift:

Charge Position Shift:

Comments or Additional information that DSA should now:

Disclosure Questionnaire:

1. Has the Company/Ownership filed for bankruptcy within the past 7 years ?

Yes

No

2. Has there been any corporate/ownership change within the past year?

Yes

No

3. Is the Company planning any change in ownership within the next year?

Yes

No

4. Does the Facility do any Fit Testing?

Yes

No

If you have answered Yes to any of the questions above, please provide an explanation below:

5. What type of PPE mask does the Facility Use?

6. Number of years the Facility has been in operation?

7. How did the Company hear about Dependable Staffing Agency, LTD?

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Seattle, Washington

Location Name: Federal Way Office

Location Address: 33600 6th Ave, S#204, Federal Way, WA 98003

Email:
[email protected]

Phone Number: +1 (888) 221-5151

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Sacramento, California

Location Name: Sacramento Office

Location Address: 455 Capitol Mall, S#335, Sacramento, CA 95814

Email: [email protected]

Phone Number: +1 (888) 256-5267

Fax: 916-993-5041

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