Your name
Your Email
Last 4 Of SSN
Date
E-Signature
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
Instructions:This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Universal Precautions & Related Competencies
Working with patients in isolation: 0★★★★−
Working with patients in restraints: 0★★★★−
Patient/Family teaching: 0★★★★−
Patient Identification: 0★★★★−
Specialty beds: 0★★★★−
End of life care/palliative care: 0★★★★−
Knowledge of "Do Not Use Abbreviations": 0★★★★−
Staff Development: 0★★★★−
Coaching and mentoring: 0★★★★−
Project management: 0★★★★−
Business development: 0★★★★−
Developing Strategic plans: 0★★★★−
Developing operational plans: 0★★★★−
Cultural competence: 0★★★★−
Personal growth and development: 0★★★★−
Ethical behavior and practice: 0★★★★−
Professional association involvement: 0★★★★−
Conflict Management: 0★★★★−
Team dynamics: 0★★★★−
Mediation/coaching: 0★★★★−
TJC Standards: 0★★★★−
OSHA Standards: 0★★★★−
Risk Management/Service Utilization: 0★★★★−
Local Department of Health: 0★★★★−
State Department of Health: 0★★★★−
Sitter Services: 0★★★★−
Age Specific Competencies
Infant (Birth - 1 year): 0★★★★−
Preschooler (ages 2–5 years): 0★★★★−
Childhood (ages 6–12 years): 0★★★★−
Adolescents (ages 13–21 years): 0★★★★−
Young Adults (ages 22–39 years): 0★★★★−
Adults (ages 40–64 years): 0★★★★−
Older Adults (ages 65–79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
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