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
Practice Settings/Experience
Academia: 0★★★★−
Ambulatory Care: 0★★★★−
Clinic: 0★★★★−
Compounding: 0★★★★−
Consulting: 0★★★★−
Correctional Facility (Jail): 0★★★★−
Diabetes: 0★★★★−
Drug Information: 0★★★★−
Formulary Management: 0★★★★−
Geriatrics: 0★★★★−
Home Health: 0★★★★−
Home Infusion: 0★★★★−
Hospital– Inpatient: 0★★★★−
Hospital– Outpatient: 0★★★★−
Infectious Disease: 0★★★★−
Long Term Care (LTC): 0★★★★−
Mail Order: 0★★★★−
Military/Government/VA: 0★★★★−
Nuclear: 0★★★★−
Oncology: 0★★★★−
Pain Management: 0★★★★−
Pediatrics: 0★★★★−
Pharmaceutical Research: 0★★★★−
Pharmaceutical Sales: 0★★★★−
Pharmacy Benefits Management (PBM): 0★★★★−
Poison Control: 0★★★★−
Psychiatric Patient Management: 0★★★★−
Public Health: 0★★★★−
Renal Patient Management: 0★★★★−
Retail– Chain: 0★★★★−
Retail– Independent: 0★★★★−
Sub-Acute Care: 0★★★★−
Veterinary: 0★★★★−
Other:
Pharmacy Software Systems
Etreby: 0★★★★−
HBS: 0★★★★−
JASRx: 0★★★★−
McKesson– 3PM: 0★★★★−
McKesson– Pharmserv: 0★★★★−
Meditech: 0★★★★−
NDC: 0★★★★−
OPUS– ISM: 0★★★★−
OSCOR: 0★★★★−
PDX: 0★★★★−
PharmNet: 0★★★★−
Pharmtrak: 0★★★★−
PROScript 2000: 0★★★★−
QS1: 0★★★★−
Renlar: 0★★★★−
Rescot– Omni-DX: 0★★★★−
Rx-Link: 0★★★★−
Speed Script: 0★★★★−
TechRx: 0★★★★−
WinPharm: 0★★★★−
Automation
Accumed/Baker Cells: 0★★★★−
BAXA– Rapid-Fill (ASF): 0★★★★−
BAXA– Repeater Pump: 0★★★★−
Baxter: 0★★★★−
Baxter– AUTOMIX Compounder: 0★★★★−
Baxter– MICROMIX Compounder: 0★★★★−
Kirby Lester: 0★★★★−
McKesson– AcuDose-Rx: 0★★★★−
McKesson– Baker Scale: 0★★★★−
McKesson– IntelliShelf-Rx: 0★★★★−
McKesson– MedCarousel: 0★★★★−
McKesson– ROBOT– Rx: 0★★★★−
McKesson– PACMED: 0★★★★−
MTS– Automated Sealers: 0★★★★−
MTS– Prepackaging: 0★★★★−
Parata– PACMED: 0★★★★−
Parata– RDS: 0★★★★−
Parata– APM: 0★★★★−
PharmASSIST– RDS ROBOTx: 0★★★★−
PharmASSIST– ROBOTx: 0★★★★−
PharmASSIST– SmartCabinet: 0★★★★−
PharmASSIST– SmartScale: 0★★★★−
Pyxis: 0★★★★−
Disease State Management
AIDS/HIV: 0★★★★−
Anticoagulation: 0★★★★−
Asthma: 0★★★★−
Cardiovascular Disease: 0★★★★−
Chemotherapy: 0★★★★−
Cystic Fibrosis: 0★★★★−
Depression: 0★★★★−
Dyslipidemia: 0★★★★−
Hormone Replacement Therapy: 0★★★★−
Hypertension: 0★★★★−
Osteoporosis: 0★★★★−
Smoking Cessation: 0★★★★−
Transplant: 0★★★★−
Clinical and Job related Experience
Admixture: 0★★★★−
Adolescent Care: 0★★★★−
Aseptic Techniques: 0★★★★−
Blister Packs: 0★★★★−
Cart Check: 0★★★★−
Cart Fill: 0★★★★−
Computerized Physician Order Entry: 0★★★★−
Discharge Counseling: 0★★★★−
DME Equipment: 0★★★★−
Drug Information Rounds: 0★★★★−
Drug Rehabilitation Programs: 0★★★★−
Emergency Room: 0★★★★−
Enteral Nutrition Products: 0★★★★−
Geriatric Care: 0★★★★−
Hazardous Drug Handling: 0★★★★−
Homeopathic Treatments: 0★★★★−
Hyperalimentation Calculation: 0★★★★−
Immunizations: 0★★★★−
Immunoglobulin Therapy: 0★★★★−
Incontinence Supplies: 0★★★★−
Infusion Pumps and Systems: 0★★★★−
Intensive Care (ICU): 0★★★★−
IV Preparation: 0★★★★−
Neonatal Intensive Care (NICU): 0★★★★−
Ostomy Supplies: 0★★★★−
OTC selection and recommendations: 0★★★★−
P&T committee participant: 0★★★★−
PCA Pumps: 0★★★★−
Pediatric Care: 0★★★★−
Psychiatric Care: 0★★★★−
Retail Compounding: 0★★★★−
Surgical Supplies: 0★★★★−
Tocolytic Therapy: 0★★★★−
TPN Preparation: 0★★★★−
Transplant Therapy: 0★★★★−
Urological Supplies: 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★★★★−
Pharmacokinetic Dosing of
Aminoglycosides: 0★★★★−
Digoxin: 0★★★★−
Lithium: 0★★★★−
Theophylline: 0★★★★−
Vancomycin: 0★★★★−
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