Fast Chart Qualification Form Step 1 of 3Please complete each of the following questions. Questions marked with " * " are required. You must complete all required fields before you will be able to submit the form to Fast Chart. Please review our Independent Contractor Requirements before completing this form. Have you read our Independent Contractor Requirements?* Yes No Full Name* Type your full name in this boxEmail* Primary Phone Number* Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about Fast Chart?*Direct Mail (postcard, etc.)Fast Chart Transcriptionist (Please list name in box below)Friend/ColleagueInternet Search Engine (i.e. Google)Magazine AdMTStars.comOtherReferring Fast Chart MT name Total hours per week* Sunday*01-23-45-67-8What time Sunday? Monday*01-23-45-67-8What time Monday? Tuesday*01-23-45-67-8What time Tuesday? Wednesday*01-23-45-67-8What time Wednesday? Thursday*01-23-45-67-8What time Thursday? Friday*01-23-45-67-8What time Friday? Saturday*01-23-45-67-8What time Saturday? Have you worked from home before? Yes No What is your reason for wanting to work from home?What version of Microsoft Office/Word do you have currently installed?*MS Office 2019MS Office 2016MS Office 2013MS Office 2010MS Office 2007Which version of Windows do you have currently installed?*Windows 10Windows 7OtherWhich type of internet connection do you use?*Cable ModemDSLFiberSatelliteT-1Wireless Broadband (ex: Verizon Wireless)Which edition of the AAMT Book of Style do you have?*1st Edition2nd EditionI do not have a copy of either edition.When will you be available to begin work as an Independent Contractor?* Have you previously performed any work with Fast Chart, Inc.?* Yes No Unsure If the answer is yes, how long ago? Step 2 of 3Please indicate your level of transcription experience (Number of years) in each field:How much DocQscribe experience do you have?None1-2 years3-4 years>5 yearsHow much EditScript experience do you have?None1-2 years3-4 years>5 yearsHow long have you transcribed in a clinical environment? None Up to 2 years 2-5 years >5 years How long have you transcribed in a hospital enviroment? None Up to 2 years 2-5 years >5 years Cardiology 0 Less than 1 1-2 3-5 >5 Consults 0 Less than 1 1-2 3-5 >5 Discharge Summaries (Clinical) 0 Less than 1 1-2 3-5 >5 Discharge Summaries (Hospital) 0 Less than 1 1-2 3-5 >5 Emergency Department 0 Less than 1 1-2 3-5 >5 Endocrinology 0 Less than 1 1-2 3-5 >5 ENT 0 Less than 1 1-2 3-5 >5 Family Practice 0 Less than 1 1-2 3-5 >5 Gastroenterology 0 Less than 1 1-2 3-5 >5 General Surgery 0 Less than 1 1-2 3-5 >5 Hematology 0 Less than 1 1-2 3-5 >5 Hepatology 0 Less than 1 1-2 3-5 >5 History & Physicals 0 Less than 1 1-2 3-5 >5 Internal Medicine 0 Less than 1 1-2 3-5 >5 Nephrology 0 Less than 1 1-2 3-5 >5 Neurology 0 Less than 1 1-2 3-5 >5 OB/GYN 0 Less than 1 1-2 3-5 >5 Oncology 0 Less than 1 1-2 3-5 >5 Operative Notes 0 Less than 1 1-2 3-5 >5 Ophthalmology 0 Less than 1 1-2 3-5 >5 Orthopedics 0 Less than 1 1-2 3-5 >5 Physical Therapy 0 Less than 1 1-2 3-5 >5 Plastics 0 Less than 1 1-2 3-5 >5 Psychology 0 Less than 1 1-2 3-5 >5 Pulmonary 0 Less than 1 1-2 3-5 >5 Radiology 0 Less than 1 1-2 3-5 >5 Rehab (Hospital) 0 Less than 1 1-2 3-5 >5 Rheumatology 0 Less than 1 1-2 3-5 >5 Urology 0 Less than 1 1-2 3-5 >5 Do you have experience in specialties that are not listed? If so, list them in the space providedStep 3 of 3Please upload your résumé OR paste it in the allotted area belowChoose a résumé file to uploadMax. file size: 300 MB.Or paste your résumé in the space provided Δ
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