Travel Nurse Assignment Confirmation Agreement Template (13-Week Contract)
Standardized 13-week travel nurse assignment agreement template. Features IRS-compliant GSA stipend packaging, guaranteed hours clauses, facility floating parameters, and cancellation stipulations.
THIS ASSIGNMENT CONFIRMATION (“Agreement”) is entered into as of [DATE], by and between [STAFFING AGENCY NAME], LLC (“Agency”), and [CLINICIAN FULL LEGAL NAME], RN (“Clinician”).
1. Assignment Details
- Facility Name: [FACILITY NAME / HOSPITAL]
- Facility Address: [STREET ADDRESS, CITY, STATE, ZIP]
- Department / Unit: [e.g., Intensive Care Unit (ICU)]
- Duration: 13 Consecutive Weeks ([START DATE] to [END DATE])
- Shift Schedule: 3 x 12-Hour Night Shifts (19:00 - 07:30)
- Contracted Hours: 36.0 Hours per Week (Guaranteed)
2. Compensation & Reimbursement Structure
Clinician compensation is structured under the Agency's IRS-compliant Accountable Plan:
- Taxable Base Hourly Wage: $[XX.XX] per worked hour.
- Taxable Overtime Rate: $[XX.XX] per hour for hours in excess of 40.0 hours/week.
- Non-Taxable Lodging Stipend: $[XXX.XX] per calendar week.
- Non-Taxable Meals & Incidentals: $[XXX.XX] per calendar week.
- Total Gross Blended Weekly Package: $[X,XXX.XX] (based on 36 hours)
3. Guaranteed Hours & Floating Policy
A. Guaranteed Hours: Agency agrees to compensate Clinician for 36.0 contracted hours per week, provided Clinician is available and in compliance.
B. Facility Cancellations: Facility may cancel up to three (3) shifts per 13-week term. Additional cancelled shifts remain fully billable.
C. Floating Protocol: Clinician agrees to float to units of comparable acuity consistent with verified competencies.
4. Signatures & Execution
How to Implement & Enforce This Template
1. Verify Permanent Tax Home Documentation
Never disburse non-taxable stipends without keeping a signed IRS Tax Home Attestation, a valid matching driver’s license, and mortgage or lease records on file.
2. Enforce Pre-Shift Primary Source Checks
Verify the clinician’s compact multi-state license on Nursys 48 hours prior to assignment start date and record the verification timestamp.
3. Define Unit Floating Boundaries
Specify that ICU nurses may float to Telemetry or Med-Surg, but cannot be assigned charge nurse duties without written consent.
4. Automate Milestone Extension Alerts
Set an automatic reminder at day 45 of the 13-week assignment to discuss contract renewal with the hospital and clinician.
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