All-in-One Form

Form #12-005

All-in-One Form
Nurse Data Sheet

Note: All Sections Must be Completed in Detail – Please Print Clearly. If you need extra space to complete any section, write
“over” in the answer area and continue your answers on the back of the page.
ALL NAMES SHOULD BE WRITTEN AS THEY APPEAR ON YOUR PASSPORT

1.0 Nurse General Details

Title:
□ Mr. □ Mrs. □ Miss □ Ms.
First Name: RODAH

Middle Name: NYAWIRA

Last Name (Family MUKUHI

Name):
Maiden Name(Family MUKUHI
Name before Marriage):
Other Names/Aliases: NONE

Full Name in Native RODAH NYAWIRA MUKUHI

Alphabet (If Alphabet other
than Roman used e.g. Hindi,
Chinese, etc.)
Present Address (include 115-20320 KINAMBA,NYAHURURU, RIFT VALLEY,KENYA Have resided at
Street address, City, Present Address
State/Province, Country since:
and Post Code as
applicable) 03 / 2017
(mm / yyyy)

Permanent Address (if

different from above i.e.
Parents Address)
Street address, City,
State/Province, Country
and Post Code

Telephone Numbers Home Number:254712596177 Work Number:

including area/country
codes:
Alternative Contact: Fax Number: Mobile Number: Email address:
254718907667 Mukuhiroda12@[Link]
Gender and Date of □ Female Date of Birth: Month Day Year
Birth:
□ Male (Month/Day/Year) 1 2 /28
/1987
Birthplace:

City of Birth:NYERI Country of Birth:KENYA

Marital Status: □ Single (Never married) □ Married □
Separated # of Children
□ Divorced □ Widowed □ Engaged # times married
Date Married: Month Day Year: Date Divorced: Month Day Year:
/ / / /

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City and Country in which
you were married:
City: Country :

Do you have a U.S. Social □ Yes, National Insurance

Security Number: Number Number:
□ No (if applicable)
Native Language: KISWAHILI & KIKUYU Languages Spoken or Read:

Nationality (i.e. based on KENYAN Country(s) of Current

country of origin / birth): Citizenship (i.e. passport):
Present Nursing REGISTERED NURSE II
Position:

Enter the name of the Name: Telephone Number:

person we should contact ERASTUS MWANGI MBURU 0718907667
in case of emergency:
Have you ever been Driving under the influence is not considered a minor traffic violation. Exceptions due to state employment
convicted of a crime law: Conviction(s) that have been sealed, expunged, eradicated, dismissed, or overturned, and California
Health & Safety Code §§11357 (b) & (c), 11360(c), 11364, 11365, 11550 marijuana-related convictions over 2
other than a minor
years old, should not be revealed.)
traffic violation?
□ Yes - If “Yes” please explain in detail on the back of this page.
□ No
Has your Spouse, or any of □ Yes - If “Yes” please explain in detail on the back of this page.
your Children been
convicted of a Felony?
□ No
Passport (s) Country of Issue: Number: Date of Expiration:
Month / Day / Year
KENYA AK1609016 06/07 / 2034
/ /
List ALL dates of previous visits and periods of residence in the United States. If never, write “NEVER”.
Use your passport as a reference to your visits. If you have or had a visa, then give the type of visa,
expiration date, and INS Alien Registration number if known. Attach an additional sheet of paper if
necessary. ALL dates must have a MONTH and YEAR.
Date of Entry: Date of Departure: City/State Visited: Type of Visa: If received Green Card
or permanent resident of
US list “A” number.
NEVER
Month Year Month Year

Month Year Month Year

Month Year Month Year

1.1 Nurse’s Father’s Information

First Name: N/A

Middle Name: N/A

Last Name (Family N/A

Name):
Address (include Street N/A
address, City, State /
Province, Country and
Post Code as applicable)
Date of Birth (Month- □ Living Date of Birth: Month Day Year
Day-Year)
□ Deceased (Month/Day/Year) / /
If Deceased, please give
Year of Death:
year of death:

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Place of Birth:
City of Birth:N/A Country of Birth: N/A
Telephone Numbers Home Number: Work Number:
including area/country N/A
codes:
1.2 Nurse’s Mother’s Information

First Name: SUSAN

Middle Name: MUKUHI

Last Name (Family GITAHI

Name):
Your Mother’s Maiden GITAHI
Name (Family Name
before Marriage):
Address (include Street 213-10107,KIRITI,NYERI, CENTRAL,KENYA
address, City, State /
Province, Country and
Post Code as applicable)

Date of Birth: □ Living Date of Birth: Month Day Year

If Deceased, please give

□ Deceased (Month/Day/Year) 0 1 / 01
/ 1952
year of death:
Year of Death:2020
Place of Birth:
City of Birth:NYERI Country of Birth: KENYA
Telephone Numbers Home Number: Work Number:
including area/country N/A N/A
codes:

1.3 Nurse’s Previous Residences

List below all places that you have lived for at least 6 months since reaching the age of 16, including
places in your country of nationality. Order answers most recent to oldest:

Residence #1
Previous Address 1165-40200 KISII,NYANZA,KENYA
(include Street address,
City, State/Province,
Country and Post Code
as applicable)

Duration of Residence: From: To:

Month: 03 Year:2009 Month: 10 Year: 2012

Residence #2
Previous Address 213-10107,KIRITI,NYERI, CENTRAL,KENYA
(include Street address,
City, State/Province,
Country and Post Code
as applicable)

Duration of Residence: From: To:

Month: 12 Year:1987 Month:03 Year:2009

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Residence #3
Previous Address N/A
(include Street address,
City, State/Province,
Country and Post Code
as applicable)

Duration of Residence: From: To:

Month: Year: Month: Year:

Residence #4
Previous Address N/A
(include Street address,
City, State/Province,
Country and Post Code
as applicable)

Duration of Residence: From: To:

Month: Year: Month: Year:

Residence #5
Previous Address N/A
(include Street address,
City, State/Province,
Country and Post Code
as applicable)

Duration of Residence: From: To:

Month: Year: Month: Year:

1.4 Spouse’s Information

If you have never been married and do not have any children please skip to Section 2.0 on Page 9.
Title:
□ M□ M □ M □ Ms.
r. rs. iss
First Name: ERASTUS

Middle Name: MWANGI

Last Name (Family MBURU

Name):
Maiden Name (Family MBURU
Name before Marriage):
Other Names/Aliases: NONE

Full Name in Native ERASTUS MWANGI MBURU

Alphabet (If Alphabet other
than Roman used e.g. Hindi,
Chinese, etc.)
Present Address (include 115-20320 KINAMBA,NYAHURURU, RIFT VALLEY,KENYA
Street address, City,
State/Province, Country
and Post Code as
applicable)
Telephone Numbers Home Number:+254718907667 Work Number:
including area/country
codes:
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U.S. Social Security National Insurance Number:
Number: (if applicable). (if applicable)
Gender and Date of □ Female Date of Birth: Month Day Year
Birth: (Month-Day-Year)
□ Male (Month/Day/Year) 05 / 02
/ 1991
Birthplace:
City of Birth: KAHURO Country of Birth: KENYA

Nationality (i.e. based on KENYAN Country(s) of Current

country of origin / birth): Citizenship (i.e. passport):
Marital Status: □ Single (Never married) □ Married □ Separated
□ Divorced □ Widowed # times married
Date Married: Month Day Year: Date Divorced: Month Day Year:
/ / / /
City and Country in which
you were married:
City: Country :
Native Language: KIKUYU Other languages ENGLISH & KISWAHILI
Spoken or Read:
Occupation(s): CLINICAL OFFICER Have you ever served in NO
the military?
Passport(s) Country of Issue: Number: Date of Expiration: mm/dd/yyyy
Month: /Day: /Year:
Month: /Day: /Year:
List ALL dates of previous visits and periods of residence in the United States. If never, write “NEVER”.
Use your passport as a reference to your visits. If you have or had a visa, then give the type of visa,
expiration date, and INS Alien Registration number if known. Attach an additional sheet of paper if
necessary. ALL dates must have a MONTH and YEAR.
Date of Entry: Date of Departure: City/State Visited: Type of Visa: If received Green
Card or permanent
resident of US list “A”
number.
NEVER
Month Year Month Year

Month Year Month Year

Month Year Month Year

List any countries you have lived in for six months or more since the age of 16:
KENYA

1.5 Child #1’s Information, Please complete for ALL of your children regardless of age. Child must be
your biological or legally adopted child.

Relationship:
□ Son □ Daughter □ Legally Adopted Son □
Legally Adopted Daughter
First Name: RYAN

Middle Name: MUTHOGA

Last Name (Family NYAWIRA

Name):
Maiden Name (Family NYAWIRA
Name before Marriage):
Other Names/Aliases: NONE

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Full Name in Native: RYAN MUTHOGA NYAWIRA

Alphabet (If Alphabet other
than Roman used e.g. Hindi,
Chinese, etc.)
Present Address (include 115-20320 KINAMBA,NYAHURURU, RIFT VALLEY,KENYA
Street address, City,
State/Province, Country
and Post Code as
applicable)

U.S. Social Security N/A National Insurance Number:

Number: (if applicable). (if applicable)
Gender and Date of □ Female Date of Birth: Month Day Year
Birth:
□ Male (Month/Day/Year) 0 6 / 02 /
2012
Birthplace:
City of Birth: NYERI Country of Birth: KENYA

Nationality (i.e. based on KENYAN Country(s) of Current

country of origin / birth): Citizenship (i.e. passport):
Marital Status: □ Single (Never married) □ Married □ Separated
□ Divorced □ Widowed
Date Married: Month / Day / Year: Date Divorced: Month / Day / Year:
/ / / /
City and Country in
which child married. City: Country:
When will Dependant
travel to US?
□ With Sponsor (Nurse) □ After Sponsor (Nurse) □ Never
Passport(s) Country of Issue: Number: Date of Expiration: mm/dd/yyyy
KENYA BK746661 Month:06 /Day:07 /Year:2034
Month: /Day: /Year:
List ALL dates of previous visits and periods of residence in the United States. If never, write “NEVER”. Use
your passport as a reference to your visits. If you have or had a visa, then give the type of visa, expiration
date, and INS Alien Registration number if known. Attach an additional sheet of paper if necessary.
ALL dates must have a MONTH and YEAR.
Date of Entry: Date of Departure: City/State Visited: Type of Visa: If received greencard or
permanent resident of US
list “A” number.
NEVER
Month Year Month Year

Month Year Month Year

Month Year Month Year

List any countries you have lived in for six months or more since the age of 16:
KENYA

1.6 Child #2’s Information

Relationship:
□ Son □ Daughter □ Legally Adopted Son □
Legally Adopted Daughter
First Name: CALLA

Middle Name: NJOKI

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Last Name(Family MWANGI
Name):

Maiden Name(Family MWANGI

Name before Marriage):
Other Names/Aliases: NONE

Full Name in Native: CALLA NJOKI MWANGI

Alphabet (If Alphabet other
than Roman used e.g. Hindi,
Chinese, etc.)
Present Address (include 115-20320 KINAMBA,NYAHURURU, RIFT VALLEY,KENYA
Street address, City,
State/Province, Country
and Post Code as
applicable)

U.S. Social Security N/A National Insurance Number:

Number: (if applicable). (if applicable)
Gender and Date of □ Female Date of Birth: Month Day Year
Birth:
□ Male (Month/Day/Year) 0 5 / 05 /
2022
Birthplace:
City of Birth: NYAHURURU Country of Birth:KENYA

Nationality (i.e. based on KENYAN Country(s) of Current

country of origin / birth): Citizenship (i.e. passport):
Marital Status: □ Single (Never married) □ Married □ Separated
□ Divorced □ Widowed
Date Married: Month / Day / Year: Date Divorced: Month / Day / Year:
/ / / /
City and Country in
which child married. City: Country:
When will Dependant
travel to US? □ With Sponsor (Nurse) □ After Sponsor (Nurse) □ Never
Passport(s) Country of issue: Number: Date of Expiration: mm/dd/yyyy
KENYA BK787575 Month:06 /Day:14 /Year:2034
Month: /Day: /Year:
List ALL dates of previous visits and periods of residence in the United States. If never, write “NEVER”. Use
your passport as a reference to your visits. If you have or had a visa, then give the type of visa, expiration
date, and INS Alien Registration number if known. Attach an additional sheet of paper if necessary. ALL
dates must have a MONTH and YEAR.
Date of Entry: Date of Departure: City/State Visited: Type of Visa: If received greencard or
permanent resident of US
list “A” number.

NEVER
Month Year Month Year

Month Year Month Year

Month Year Month Year

List any countries you have lived in for six months or more since the age of 16:
KENYA

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1.7 Child #3’s Information

Relationship:
□ Son □ Daughter □ Legally Adopted Son □
Legally Adopted Daughter
First Name: ROGAN

Middle Name: MBURU

Last Name(Family MWANGI

Name):
Maiden Name(Family MWANGI
Name before Marriage):
Other Names/Aliases: NONE
Full Name in Native: ROGAN MBURU MWANGI
Alphabet (If Alphabet other
than Roman used e.g. Hindi,
Chinese, etc.)
Present Address (include 115-20320 KINAMBA,NYAHURURU, RIFT VALLEY,KENYA
Street address, City,
State/Province, Country
and Post Code as
applicable)
U.S. Social Security N/A National Insurance Number:
Number: (if applicable). (if applicable)
Gender and Date of □ Female Date of Birth: Month Day Year
Birth:
□ Male (Month/Day/Year) 0 5 / 05 /
2022
Birthplace:
City of Birth: NYAHURURU Country of Birth: KENYA

Nationality (i.e. based on KENYA Country(s) of Current

country of origin / birth): Citizenship (i.e. passport):
Marital Status: □ Single (Never married) □ Married □ Separated
□ Divorced □ Widowed
City and Country in
which child married. City: Country:
When will Dependant
travel to US? □ With Sponsor (Nurse) □ After Sponsor (Nurse) □ Never
Passport(s) Country of Issue: Number: Date of Expiration: mm/dd/yyyy
KENYA BK735707 Month:06 /Day:07 /Year:2034
Month: /Day: /Year:
List ALL dates of previous visits and periods of residence in the United States. If never, write “NEVER”. Use
your passport as a reference to your visits. If you have or had a visa, then give the type of visa, expiration
date, and INS Alien Registration number if known. Attach an additional sheet of paper if necessary. ALL
dates must have a MONTH and YEAR.
Date of Entry: Date of Departure: City/State Visited: Type of Visa: If received greencard or
permanent resident of US
list “A” number.

NEVER
Month Year Month Year

Month Year Month Year

Month Year Month Year

List any countries you have lived in for six months or more since the age of 16:
KENYA
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2.0 Education History

2.1 Primary School Education Use the back of this page for additional schools.

Name of Primary KIRITI PRIMARY SCHOOL

School:
City of School: NYERI

State/Province of CENTRAL Country of KENYA

School: School:
Date Started:
Month/Year Month:01 Year:1993
Date Completed:
Month/Year Month:11 Year: 2001
Qualifications: □ Degree □ Diploma □ Certificate
□ Other □ None

2.2 Secondary/High School Use the back of this page for additional schools.

Name of KIRITI SECONDARY SCHOOL

Secondary/High
School:
City of School: NYERI

State/Province of CENTRAL Country of KENYA

School: School:
Date Started:
Month/Year Month: 02 Year:2002
Date Completed:
Month/Year Month:11 Year:2005
Qualifications: □ Degree □ Diploma □ Certificate
□ Other □ None

2.3 Nursing School Use the back of this page for additional schools.

Name of Nursing KISII MEDICAL TRAINING COLLEGE

School:
Street Address of 1165-40200
School:

City of School: KISII

State/Province of NYANZA Country of KENYA

School: School:
Date Started:
Month/Year Month:03 Year:2009
Date Completed:
Month/Year Month:12 Year:2012
Qualifications: □ Degree □ Diploma □ Certificate □ Other
□ Bachelor of Science in Nursing (BSN)
□ None
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2.4 Nursing School Transcripts Use the back of this page for additional schools.

Name of Contact that issues your Telephone Numbers including Cost of Transcripts in US $:
nursing school’s transcripts: area/country codes:
KENYA MEDICAL TRAING COLLEGE +254706541869 8 US DOLLARS
Does your Nursing Diploma give you the
right to practice nursing without a license?
□ Yes □ No
2.5 Licenses
List all RN Licenses received (Even those you did not practice under).

Country of Name of Nursing Issuance Date

License Date of Full Name as appears on
Issue: Board: Number: Expiration: license:
Month / Day / Year
Kenya Nursing Council / /

/ /

/ /

/ /

3.0 Employment History

Please list in chronological order the details of your Work experience for the last 10 years, starting
with your present job.

3.1 Present Employer

Name of Employer: NYAHURURU COUNTY & REFERRAL HOSPITAL

Street Address: 86,NYAHURURU ,RIFT VALLEY,KENYA
City, State/Province:
Country:

Kind of Business: (i.e. HOSPITAL Specialty(s): MEDICAL SURGICAL

Hospital, Health Clinic) (i.e. Midwifery,
ICU)
Date Started: 03/2017 Date Left: Presently Employed
Month/Year
Average Number of 40 Shift(s) Worked: EVENING SHIFT
Hours Worked per MORNING SHIFT
Week : NIGHT SHIFT
List your job duties beyond the basic scope of nursing practice. (i.e. EKG interpretation, hemodynamic monitoring,
administer blood products, etc.)
EKG INTERPRETATION
CANNULATION
CATHETERIZATION
PRE-POST OP MONITORING

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3.2 Previous Employer

Name of Previous CONSOLATA HOSPITAL MATHARI

Employer: IHURURU ROAD
Street Address: 25-10100,NYERI
CENTRAL,KENYA
City, State/Province:
Country:

Kind of Business: (i.e. HOSPITAL Specialty(s): MEDICAL SURGICAL

Hospital, Health Clinic) (i.e. Midwifery, NEW BORN UNIT
ICU)
Date Started: 01/2013 Date Left: 08/2016
Month/Year
Average Number of 40 Shift(s) Worked: MORNING SHIFT
Hours Worked per EVENING SHIFT
Week : NIGHT SHIFT
List your job duties beyond the basic scope of nursing practice. (i.e. EKG interpretation, hemodynamic monitoring,
administer blood products, etc.)
WOUND CARE
NG-TUBE FEEDING
BLOOD PRODUCTS ADMINISTRATION
CANNULATION

3.3 Previous Employer

Name of Previous N/A

Employer:
Street Address:
City, State/Province:
Country:

Kind of Business: (i.e. Specialty(s):

Hospital, Health Clinic) (i.e. Midwifery,
ICU)
Date Started: Date Left:
Month/Year
Average Number of Shift(s) Worked:
Hours Worked per
Week :
List your job duties beyond the basic scope of nursing practice. (i.e. EKG interpretation, hemodynamic monitoring,
administer blood products, etc.)

3.4 Previous Employer Use the back of this page for additional employers.
Name of Previous
Employer:
Street Address:
City, State/Province:
Country:

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Kind of Business: (i.e. Specialty(s):
Hospital, Health Clinic) (i.e. Midwifery,
ICU)
Date Started: Date Left:
Month/Year
Average Number of Shift(s) Worked:
Hours Worked per
Week :

List your job duties beyond the basic scope of nursing practice. (i.e. EKG interpretation, hemodynamic monitoring,
administer blood products, etc.)

3.5 Placement Information Use the back of this page if you need additional space.

Do you hold a valid If “NO”, are you willing to

driver’s license? □ Yes acquire a license before you travel □ Yes □ No
□ No to the US?
Have you ever worked in the US before? If “YES”, please give a description of
where and when you worked in the on the back of this page. □ Yes □ No

Do you have a preference regarding your location of employment in the US?

□ Yes □ No

If yes, where is your preference? [Link] [Link] CAROLINA

Do you agree and acknowledge that if you sign a contract with OGP, that
contractually we require flexibility regarding location and we cannot guarantee □ Yes □ No
any specific location?
Do you have any family living in other US states? If Yes, please list locations.
□ Yes □ No

Please indicate Have you ever signed a contract

“Yes” as your □ Yes with another employment agency □ Yes □ No
acceptance / or placement company?
acknowledgemen □ No
t of the terms If you answered “YES” in the box above, then
requiring you to please explain in detail on the back of this
float to other page.
clinical areas
and to work
different shifts.

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4.0 Immigration Information

4.1 USCIS Petition If you answer yes to either question below write an explanation on back of page.
Are you (your dependent) currently in U.S. Removal proceedings (i.e. □ Yes □
Deportation, Exclusion)? No
Has any Immigrant Visa Petition ever been filed by you or on your behalf? □ Yes □
No
If you answer yes to either question above, please explain:

4.2 Department of State Petition

Name of Person Relationship: Date of Birth: When will this person travel to the US:
Accompanying Nurse to US: (Husband, Wife, Son, Check the box that applies.
or Daughter) Month / Day / Year
ERASTUS MWANGI HUSBAND 05/02/1991 □ With Nurse □ After Nurse □ Never
RYAN MUTHOGA SON 06/02 /2012 □ With Nurse □ After Nurse □ Never
CALLA NJOKI DAUGHTER 05/05 /2022 □ With Nurse □ After Nurse □ Never
ROGAN MBURU SON 05/05 /2022 □ With Nurse □ After Nurse □ Never
CAYLE WANJIKU DAUGHTER 05/05 /2022 □ With Nurse □ After Nurse □ Never
Professional [Link] 2. 3.
Organizations/Associations
to which you belong:
Did you serve in the If “YES”, then N/A
Military? □ Yes □ No please list country.
Rank and Position: N/A Branch of Service: N/A
Military Specialty: N/A Military Occupation: N/A
Dates of Service: From: Month / Day / Year: To: Month / Day / Year:
/ / / /
/ / / /

5.0 CGFNS / US Licensure Information

5.1 CGFNS information.
Have you ever If “YES”, then please write CGFNS#:
applied for any □ Yes □ No down your CGFNS number
service offered and your username and Username:
CES CVS Visascreen
by CGFNS? password
When? Password:
Have you ever If “YES”, please give the date
taken the □ Yes □ No you took the exam? Month Day Year
CGFNS Exam?

Did you pass the Were you issued a CGFNS

CGFNS Exam? □ Yes □ No Certificate? □ Yes
□ No
□ Not Applicable. Date CGFNS Certificate was
Month Day Year
issued?

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If you are scheduled to take the CGFNS Exam,
then please write your future exam date. Month Day Year

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5.2 Visa Screen information.

Have you ever applied If “YES”, then please

for a VisaScreen to □ Yes □ No write down your ICHP
ICHP? number.
Were you issued a If “YES”, then please
VisaScreen □ Yes □ No write down the date it Month Day Year
Certificate? was issued?

5.3 NCLEX

Have you ever taken Did you pass the

the US-RN NCLEX □ Yes NCLEX? □ Yes □ No
Exam? □ No
State:TEXAS
Do you have an Were you issued a US
application in process □ Yes RN License? If “YES”, □ Yes □ No
with a Board of □ No write the date it
Nursing? expires. Month Day Year
If you were issued a Please list the date(s)
Month Day Year
US-RN license(s), of expiration for the
please list the US US license(s)?
State(s) in which you Month Day Year
hold a license?
Month Day Year

5.3 English Language Information

Test Taken: Month / Day / Year Registration #: Score:

□ IELTS / /
□ TOEFL-iBT / /

Nurse Signature Date

Recruiter Signature Date

Immigration Signature Date

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