Free 53516.pdf - Indiana

NEW HIRE NURSE WORKSHEET
State Form 53516 (6-08)

INDIANA STATE PERSONNEL DEPARTMENT

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Name Title of class and code License number

Social Security Number * XXX - XX -

Date of Issue (month, day, year)

Place of Employment

Begin Date (month, day, year)

End Date Full Time / (month, day, year) Part time

Total Years / Months

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Education: BSN MSN
Years of Experience

Total Nursing Experience:

Comparative Employees:
Employee Identification Number Employee Identification Number

BSN MSN BSN MSN

Annual Salary:

Years of Experience

Annual Salary:

Salary Offered:

Salary Accepted:

Rationale for Rate of Salary Offered:

Signature:

Date:

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