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
Skills
Vital Sign - PULSE: 0★★★★−
Vital Sign - RESPIRATION: 0★★★★−
Vital Sign - LUNG SOUNDS: 0★★★★−
Vital Sign - BLOOD PRESSURE: 0★★★★−
Vital Sign - PULSE OXIMETRY: 0★★★★−
Basic Airway - OROPHARYNGEAL AIRWAY (OPA): 0★★★★−
Basic Airway - NASOPHARYNGEAL AIRWAY (NPA): 0★★★★−
Basic Airway - ORAL SUCTIONING: 0★★★★−
Basic Airway - BAG VALVE MASK: 0★★★★−
Basic Airway - OXYGEN ADMINISTRATION: 0★★★★−
Advanced Airway - MULTI-LUMEN AIRWAY (COMBI-TUBE): 0★★★★−
Patient Assessment - TRAUMA: 0★★★★−
Patient Assessment - MEDICAL: 0★★★★−
Bleeding Control/Shock Management: 0★★★★−
PNEUMATIC ANTI SHOCK GARMENT (MAST): 0★★★★−
Spinal Immobilization - B/B (SUPINE PT.): 0★★★★−
Spinal Immobilization - KED (SEATED PT.): 0★★★★−
Helmet Removal - FOOTBALL: 0★★★★−
Helmet Removal - MOTORCYCLE: 0★★★★−
Splinting - LONG BONE: 0★★★★−
Splinting - BIPOLAR TRACTION (HARE): 0★★★★−
Splinting - UNIPOLAR TRACTION (SAGER): 0★★★★−
Scoop Stretcher: 0★★★★−
BLS/ALS - Cardiac Arrest Management (AED): 0★★★★−
BLS/ALS - Nitroglycerin Administration (NTG): 0★★★★−
BLS/ALS - Epinephrine Administration (EPI): 0★★★★−
CPR - ADULT / CHILD / INFANT: 0★★★★−
FBAO - ADULT / CHILD / INFANT: 0★★★★−
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