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
Knowledge of Assessment Process
Psychosocial assessment (social history, living situation, etc): 0★★★★−
Communication Abilities
Develop and maintain communication on complex matters: 0★★★★−
Personal and People Development
Develop oneself and contribute to the development of others: 0★★★★−
Quality Improvement & Service
Contribute to service improvement & maintain quality: 0★★★★−
Health Protection & Well Being
Implement aspects of a protection plan and review its effectiveness: 0★★★★−
High risk intervention / patient vulnerability or safety risk: 0★★★★−
Monitor and maintain health, safety and security of self and others: 0★★★★−
Provide crisis intervention: 0★★★★−
Care Planning
Assess complex needs and develop, monitor and review care plans: 0★★★★−
Knowledge and Information Resources
Organize knowledge/resources and provide information: 0★★★★−
Demonstrates respect for patient/family confidentiality: 0★★★★−
Documentation Skills (accurate, timely, complete): 0★★★★−
Counseling for long range planning and decision making: 0★★★★−
Equality and Diversity
Promote equality and value diversity: 0★★★★−
Experience in all or any of the following
Medical Social Work: 0★★★★−
School Social Work: 0★★★★−
Clinical Social Work: 0★★★★−
Social Work-Admin/management: 0★★★★−
Social Work-Case Manager: 0★★★★−
International Social Work: 0★★★★−
Social Work-Children & Families: 0★★★★−
Social Work in Acute Psychiatric Hospital: 0★★★★−
Forensic Social Work: 0★★★★−
Employment/Occupational Social Work: 0★★★★−
Social Work-Community Organizer: 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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