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
Surveillance
Performs targeted surveillance: 0★★★★−
Outbreak investigations: 0★★★★−
Collaboration with Infection Control Committee: 0★★★★−
Collaboration with Hospital Epidemiologist: 0★★★★−
Performance improvement projects related in communicable diseases: 0★★★★−
Collects, monitors, and maintains data using facility HER: 0★★★★−
Utilize Center for Disease Control (CDC): 0★★★★−
Infection criteria: 0★★★★−
TB, AIDS: 0★★★★−
Documentation and investigation techniques: 0★★★★−
Rounds of hospital units: 0★★★★−
Case definition, and other related patient care issues: 0★★★★−
Monitor infection control practices: 0★★★★−
Nosocomial infections or AHIs, MRSAs: 0★★★★−
Health care workers exposures: 0★★★★−
Tracing the possible sources of infection or transmission of microorganisms: 0★★★★−
Identification of Problems
Regularly meet with the hospital Epidemiologist: 0★★★★−
Risk reduction among patients, facility staff, volunteers, students, and visitors: 0★★★★−
Understand the transmission and break of infections: 0★★★★−
Identification of epidemiologically important issues for Infection Control Committee: 0★★★★−
Hospital Epidemiologist, and Administration
Design COA including Surveillance, Outbreak Investigations, and Performance Improvement Projects: 0★★★★−
Communicable diseases reporting as required by the state and the local health authority: 0★★★★−
Compliance with federal and state laws regarding medical wastes, chemicals in the workplace, infectious disease exposures: 0★★★★−
OSHA NIOSH standards: 0★★★★−
Blood borne pathogens and respiratory pathogens: 0★★★★−
Chart review: 0★★★★−
Policies and Procedures
Infection Control policies associated with infection: 0★★★★−
Staff practices associated with infection control: 0★★★★−
Professional guidelines (CDC, APIC, etc.): 0★★★★−
The Joint Commission guidelines on infection Control: 0★★★★−
Infection Control Plan to reflect and meet any required changes: 0★★★★−
Coordination
Acts as department liaison for Infection Control Department: 0★★★★−
Act as consultant for the facility Infection Control activities: 0★★★★−
Interdepartment and personnel coordination: 0★★★★−
Risk reduction, transmission and improved infection control practices: 0★★★★−
Provide coordinated services to patients for the improvement of overall Patient care: 0★★★★−
Education
In-services of all and current employees on Infection Control: 0★★★★−
Orientation programs of new employees on Infection Control: 0★★★★−
Infection Control techniques and Policies and Procedures: 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★★★★−
