Clinical Assignment Request

Date:

Person Requesting Assignment:

Title:

Position Title:

Union Status:

Non Union Union (Position cannot exceed 90 days)

Assignment Address:

City:

State:

Zip Code:

Assignment Location: (Building/ Suite/ Unit)

Work Schedule/Hours:

Start Date:

End Date:

Supervisor/Report To:*

(Please print title *must be manager/supervisor level)

Phone:

Email:

Required Skills/Certification/Licensure:

Description of Duties:

Please attach job description:

Reason for Request:

(If no reason given, form will be sent back)

Does the temporary need to be EPIC trained?

Yes No

Please note: Intrastaff can schedule basic EPIC courses. Department specific will be scheduled and paid for by department.

**Temporary has to work a minimum of 12 weeks before being hired by any affiliate.

Billing Information (*required to provide):

Department:*

Facility:*

Send Invoice To:*

Email:*

Phone:*

Cost Center/Budget Number:*

Timekeeping:

Lawson Unit Kronos Unit

Kronos Approver:

Managers are responsible for approving temp labor hours weekly by 1pm each Monday.

* If you do not have access to Kronos or Lawson for timekeeping purposes, please notify the Intrastaff Staffing Coordinator

Reminder: Per JHHS policy HR-100, temporary employees shall not be employed in an assignment for more than six months except during exceptional circumstances with the approval of the Office of HR Consulting and Labor Relations.

Administrator's Approval: (please type name)*

COVID-19 Updates