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
Processing
Single instruments: 0★★★★−
Endoscopes: 0★★★★−
Repair: 0★★★★−
Sets/Trays: 0★★★★−
Care of instruments: 0★★★★−
Other (list):
Decontamination
Manual cleaning: 0★★★★−
Washer sterilizer: 0★★★★−
Soiled linen: 0★★★★−
Disinfectants: 0★★★★−
Sharps: 0★★★★−
Disposable items: 0★★★★−
Cleaning equipment: 0★★★★−
Detergents: 0★★★★−
Dress code: 0★★★★−
Steam Sterilization
Chart recording: 0★★★★−
Biological monitoring: 0★★★★−
Time: 0★★★★−
Testing/Monitoring: 0★★★★−
Tests
Test control: 0★★★★−
Recording: 0★★★★−
Assembly and Preparation
Wrapping materials: 0★★★★−
Autoclave tape: 0★★★★−
Dust covers: 0★★★★−
Proper towel/linen folding: 0★★★★−
Proper labeling: 0★★★★−
Expiration dates: 0★★★★−
Packing for steam: 0★★★★−
Heat sealing: 0★★★★−
Instrument count sheets: 0★★★★−
Placing instruments on trays: 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★★★★−
Print
