Legal Nurse Consultants of Southern California -Subcontractor Application

Consultant and Expert Witness Information Form

If interested in being considered for a subcontracting nurse consultant position and/or expert witness, please complete the Information Form and submit.

Name:

* required field

Date:

Title:

Address:

City, State & Zip:

Phone # :

* required field

(please indicate if cell or home/business)

Emergency Phone:

Contact Person:

E-Mail for project communication:

* required field

Current Position:

# Years as a RN:

Highest level of education:

Current Certifications:

Previous work as a legal nurse consultant:

Yes

What Type:

Duration:

Previous Expert Witness Experience:

Yes

Area of Expertise:

Number of times deposed:

Number of times testified in court:

% of plaintiff cases:

% of defense cases:

Comments:

Computer experience

MS Word

Yes

Excel

Yes

Adobe Acrobat

Yes

Case Map

Yes

Other:

Rate Self:

I Use:

I have attended workshops/classes for legal nurse consulting:

Yes

When:

Where:

Hours/wk available for project:

Best Time to Contact:

Please Answer the Following Questions:

Define the Standard of Care:

Define the Standard of Practice::

List the four elements of malpractice:

Who is the most important person of the case?

Why are manhole covers round (in 50 words or less)?

I understand submission of this information is a guarantee the information is true and accurate.

I understand submission of this information is not a guarantee of hire.