Healthcare Screen Request Form

Please complete this form to request background and/or drug screens for candidates. Screens will only be ordered for candidates that have met the credentialing requirements and require completed screens prior to submission for assignment.

Date*
MM slash DD slash YYYY
Completed By: AD or recruiter*
First Last
Your Email*
Your Company Name*
Candidate Name(s)*
Note: Multiple candidates with same assignment and request details can be added to this from by clicking the + symbol to add additional names.
Name Email Phone
Position Screening For*
VMS (if applicable)
Customer / Facility / Network Name*
Working Location*
City State
Projected Start Date*
MM slash DD slash YYYY
Has the candidate completed USA Onboarding Portal - Avionte?*
- Yes
- No
Has the candidate completed Nurse Competency? (Healthcare Division Only)*
- Yes
- No
Assignment Type*
- Standard Temporary / Contract
- Travel
- Per Diem
Screens Requested*
- SSN Authentication
- OFAC/SDN List Check
- OIG Sanction History
- Sam.Gov
- National Criminal Database
- Statewide Criminal History
- County Criminal History
- Sex Offender (nationwide)
- Motor Vehicle Report
- cp 10 panel lab based + methaqualone
- cp_5_panel_DOT_Labcorp
- cp Instant 10 Panel Drug LC
- cp Instant 5 Panel Drug LC
- Other (if other specify below)
If checked Other above, please specify
Notes / Specific Instructions
Uploads
Additional Document(s)
If you have any other documents you wish to share, you can upload them here. Multiple files can be uploaded.
Drop files here or

Max. file size: 256 MB.
Name
This field is for validation purposes and should be left unchanged.

Name	Email	Phone