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Wurah Care Solutions – Staff Request Form

Reliable Healthcare Staffing Starts Here

Request qualified and verified healthcare professionals tailored to your facility’s needs. Our team will review your request and respond promptly.

🔒 Confidential • Professional • Fast Response

FACILITY INFORMATION

Facility Name

*

Contact Person Name

*

Position/Title

*

Phone Number

*

Email Address

*

Facility Address

*

City

*

State

*

Zip Code

*

STAFFING REQUIREMENTS

Type of Staff Needed

*

Type of Staff Needed

A

RN (Registered Nurse)

B

LVN/LPN

C

CNA

D

HHA

E

Caregiver / Companion

F

Phlebotomist

G

EKG Technician

H

Other

If Other, please specify:

*

Number of Staff Needed Per Role

*

Work Type

*

Work Type

A

Full-Time

B

Part-Time

C

Per Diem / PRN

D

Temporary / Contract

E

Travel Assignment

F

Other

Shift Required

*

Shift Required

Day Shift

Night Shift

Flexible

Rotating Shift

Other

SCHEDULE DETAILS

Start Date

*

End Date (if temporary)

*

Work Days Needed

*

Work Days Needed

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Other

JOB DETAILS

Job Description / Duties

*

Special Requirements or Certifications (e.g., BLS, ACLS, experience, language, etc.)

*

BILLING & RATE

Preferred Hourly Rate Range

*

Any Additional Notes

*

Urgency Level

*

Urgency Level

A

Urgent (Immediate placement)

B

Within 1 week

C

Flexible timeline

Privacy & Confidentiality Notice

Wurah Care Solutions collects this information solely for staffing coordination, placement, and communication purposes. All information is handled securely and shared only with authorized personnel and qualified professionals as necessary. We do not sell or misuse client information.

I agree to the Privacy & Confidentiality terms above

*

I agree to the Privacy & Confidentiality terms above

Full Name

*

By typing your name above, you agree that your electronic signature is legally binding.

Electronic Signature

*

Signature

Date

*