OHSU Bremerton Nurse Corps Data Sheet
Date:
Name(Last, First MI):
E-mail address:
Primary phone number: Is text message o.k.?
Rank:Date of rank (DOR):
Bonus accepted? When month, year obligation ends?
DCOIC completion?
Where do you drill/Detachment letter?
Prior Active Duty experience? If yes, briefly specify community and duration:
NOBC's (i.e., 0944, 0904) if known:
Subspecialty codesofficially granted (codes are listed below)if known:
AQD officially granted if known:
Do you have a Master’s degree? If yes, specify type/year:
Do you have DNP/PhD? If yes, specify type/year:
Are you board certified in any specialty? If yes, specify type, agency, and year:
Certifications/Verifications: Month/year
BLS (Q2yr) / Completion: / TNCC(Q4yr) / Completion:ACLS (Q2yr) / Completion: / ENPC (Q4yr) / Completion:
PALS (Q2yr) / Completion: / ABLS (Q4yr) / Completion:
NRP (Q2yr) / Completion: / WBEMT (once) / Completion:
C4 (once)
CBRNE / Completion:
Completion:10/2014 / TCCC (once) / Completion:
Privacy act statement: the authority to request this information is contained in 5 u.s.c.301 departmental regulations the information will be used to assist in determining the nursing department’s capabilities.
June 2014
OHSU Bremerton Nurse Corps Data Sheet
Civilian employment and/or how you achieve the 144 hours of clinical sustainment annually (number of hours per week or month that you perform hands-on nursing care).
Deployment experience (last 5 years):.
If you have CV orResume, please attach to your e-mail with this form.
Anything else you would like us to know about you?
NOBC CODES
0904: Critical Care Nurse
0906: Emergency/Trauma Nurse
0925: Clinical Spec Nurse
0932: Perioperative Nurse
0944: Professional Registered Nurse
0952: Nurse Anesthetist
0963: Primary Care Nurse Practitioner
FACT SHEETS FOR SUBSPECIALTY CODES
1900: Professional Nursing
1900D: Nursing Research
1903: Nursing Education
1910: Medical-Surgical Nursing
1920: Maternal/Infant Nursing
1922: Pediatric Nursing
1930: Psychiatric Nursing
1940: Community/Public Health Nursing
1945: Emergency/Trauma Nursing
1950: Perioperative Nursing
1960: Critical Care Nursing
1964: Neonatal Intensive Care Nursing
1972: Nurse Anesthesia
1974: Pediatric Nurse Practitioner
1976: Family Nurse Practitioner
1980: Women’s Health Nurse Practitioner
1981: Nurse Midwife
3130: Manpower Systems Analysis
3150: Education & Training Management Systems
Save document as “last name,first name 2018” and send to SNE Denise Elliot at , please cc Asst. SNE, CDR Jennifer Wilcox at
Privacy act statement: the authority to request this information is contained in 5 u.s.c.301 departmental regulations the information will be used to assist in determining the nursing department’s capabilities.
June 2014