{"id":2251,"date":"2023-04-28T07:38:24","date_gmt":"2023-04-28T07:38:24","guid":{"rendered":"https:\/\/www.22ndhealth.com\/?page_id=2251"},"modified":"2023-05-01T06:32:02","modified_gmt":"2023-05-01T06:32:02","slug":"staffing-request-form","status":"publish","type":"page","link":"https:\/\/www.22ndhealth.com\/staffing-request-form\/","title":{"rendered":"Staffing Request Form"},"content":{"rendered":"<section class=\"fw-main-row  employer_form ls ms section_padding_top_65 section_padding_bottom_90 background_cover\" style=\"background-image:url(http:\/\/www.22ndhealth.com\/wp-content\/uploads\/2023\/03\/Mask-Group-3.png);\">\n\n\t\t<div class=\"container\">\n\t\t<div class=\"row\">\n\t\t\t<p><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2256\"><form id=\"wpforms-form-2256\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2256\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/2251\" data-token=\"9526bee061a31605db833a34f69aed25\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-2256-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2256-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" placeholder=\"First Name\" aria-errormessage=\"wpforms-2256-field_1-error\" required><label for=\"wpforms-2256-field_1\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2256-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" placeholder=\"Last Name\" aria-errormessage=\"wpforms-2256-field_1-last-error\" required><label for=\"wpforms-2256-field_1-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2256-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-2256-field_2\">Job Title <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2256-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" placeholder=\"Job Title\" aria-errormessage=\"wpforms-2256-field_2-error\" required><\/div><div id=\"wpforms-2256-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2256-field_3\">Name of Organisation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2256-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"Name of Oraganisation\" aria-errormessage=\"wpforms-2256-field_3-error\" required><\/div><div id=\"wpforms-2256-field_14-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">Type of Facility <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2256-field_14\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-2256-field_14_4\" name=\"wpforms[fields][14]\" value=\"Acute Care\" aria-errormessage=\"wpforms-2256-field_14_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_14_4\">Acute Care<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-2256-field_14_5\" name=\"wpforms[fields][14]\" value=\"Long Term Care\" aria-errormessage=\"wpforms-2256-field_14_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_14_5\">Long Term Care<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-2256-field_14_6\" name=\"wpforms[fields][14]\" value=\"Skilled Nursing Facility\" aria-errormessage=\"wpforms-2256-field_14_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_14_6\">Skilled Nursing Facility<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-2256-field_14_7\" name=\"wpforms[fields][14]\" value=\"Other\" aria-errormessage=\"wpforms-2256-field_14_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_14_7\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2256-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-2256-field_6\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2256-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" placeholder=\"City\" aria-errormessage=\"wpforms-2256-field_6-error\" required><\/div><div id=\"wpforms-2256-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-2256-field_8\">State \/ Territory (Headquaters) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2256-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" placeholder=\"State \/ Territory\" aria-errormessage=\"wpforms-2256-field_8-error\" required><\/div><div id=\"wpforms-2256-field_9-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-2256-field_9\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-2256-field_9\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][9]\" placeholder=\"+00-00000-00000\" aria-errormessage=\"wpforms-2256-field_9-error\" required><\/div><div id=\"wpforms-2256-field_10-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-2256-field_10\">Work Email Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2256-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" placeholder=\"abc@example.com\" spellcheck=\"false\" aria-errormessage=\"wpforms-2256-field_10-error\" required><\/div><div id=\"wpforms-2256-field_11-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Staffing Type <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2256-field_11\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_4\" name=\"wpforms[fields][11][]\" value=\"Nursing (Travel)\" aria-errormessage=\"wpforms-2256-field_11_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_4\">Nursing (Travel)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_5\" name=\"wpforms[fields][11][]\" value=\"Nursing (Per Diem)\" aria-errormessage=\"wpforms-2256-field_11_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_5\">Nursing (Per Diem)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_6\" name=\"wpforms[fields][11][]\" value=\"Allied\" aria-errormessage=\"wpforms-2256-field_11_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_6\">Allied<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_7\" name=\"wpforms[fields][11][]\" value=\"Interim Leadership\" aria-errormessage=\"wpforms-2256-field_11_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_7\">Interim Leadership<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_8\" name=\"wpforms[fields][11][]\" value=\"Non Clinical\" aria-errormessage=\"wpforms-2256-field_11_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_8\">Non Clinical<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_9\" name=\"wpforms[fields][11][]\" value=\"Locum Tenens\" aria-errormessage=\"wpforms-2256-field_11_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_9\">Locum Tenens<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_10\" name=\"wpforms[fields][11][]\" value=\"Shifts\/Internal Resource Pool\/Float Pool\" aria-errormessage=\"wpforms-2256-field_11_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_10\">Shifts\/Internal Resource Pool\/Float Pool<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_11\" name=\"wpforms[fields][11][]\" value=\"Contingent Perm (Perm Staffing, RPO)\" aria-errormessage=\"wpforms-2256-field_11_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_11\">Contingent Perm (Perm Staffing, RPO)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_12\" name=\"wpforms[fields][11][]\" value=\"Aya CoreHire (Job Posting Services\/Support)\" aria-errormessage=\"wpforms-2256-field_11_12-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_12\">Aya CoreHire (Job Posting Services\/Support)<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_13\" name=\"wpforms[fields][11][]\" value=\"Advisory (Insourcing, Workforce Consulting, and Others)\" aria-errormessage=\"wpforms-2256-field_11_13-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_13\">Advisory (Insourcing, Workforce Consulting, and Others)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_14\" name=\"wpforms[fields][11][]\" value=\"International\" aria-errormessage=\"wpforms-2256-field_11_14-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_14\">International<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_15\" name=\"wpforms[fields][11][]\" value=\"Labor Disruption\" aria-errormessage=\"wpforms-2256-field_11_15-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_15\">Labor Disruption<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-2256-field_11_16\" name=\"wpforms[fields][11][]\" value=\"Other (Please specify)\" aria-errormessage=\"wpforms-2256-field_11_16-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2256-field_11_16\">Other (Please specify)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2256\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2256\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img src=\"https:\/\/www.22ndhealth.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/p>\t\t<\/div>\n\t<\/div>\n<\/section>\n\n","protected":false},"excerpt":{"rendered":"<p>Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastJob Title *Name of Organisation *Type of Facility *Acute CareLong Term CareSkilled Nursing FacilityOtherCity *State \/ Territory (Headquaters) *Phone Number *Work Email Address *Staffing Type *Nursing (Travel)Nursing (Per Diem)AlliedInterim LeadershipNon ClinicalLocum TenensShifts\/Internal Resource Pool\/Float PoolContingent Perm [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/full-width.php","meta":{"om_disable_all_campaigns":false,"_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/pages\/2251"}],"collection":[{"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/comments?post=2251"}],"version-history":[{"count":7,"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/pages\/2251\/revisions"}],"predecessor-version":[{"id":2285,"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/pages\/2251\/revisions\/2285"}],"wp:attachment":[{"href":"https:\/\/www.22ndhealth.com\/wp-json\/wp\/v2\/media?parent=2251"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}