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.
Adolescents (12–18 years): 0★★★★−
Elderly Adults (over 79+): 0★★★★−
Infant (1 month–1 year): 0★★★★−
Middle Adults (39–64 years): 0★★★★−
Newborn/Neonate (birth–30 days): 0★★★★−
Older Adults (64–79 years): 0★★★★−
Preschooler (3–5 years): 0★★★★−
School Age (5–12 years): 0★★★★−
Toddler (1–3 years): 0★★★★−
Young Adults (18–39 years): 0★★★★−
Access/Management of Central Lines: 0★★★★−
Access/Management of Implanted Ports: 0★★★★−
Administration of Blood/Blood Products: 0★★★★−
Adult Respiratory/Cardiac Arrest: 0★★★★−
Automated Med Dispensing Systems: 0★★★★−
Care of Patient in Restraints: 0★★★★−
Crash Carts: 0★★★★−
Defibrillators: 0★★★★−
Isolation Precautions: 0★★★★−
Knowledge of Anatomy: 0★★★★−
Knowledge of Current IV Therapy Guidelines: 0★★★★−
List Types (Automated Med Dispensing Systems):
Moderate Conscious Sedation: 0★★★★−
Participation on Code Teams: 0★★★★−
Patient/Family Education: 0★★★★−
Pediatric Respiratory/Cardiac Arrest: 0★★★★−
Sedation Reversal Agents: 0★★★★−
Standard Precautions: 0★★★★−
Titration of Drips: 0★★★★−
CDC: 0★★★★−
INS: 0★★★★−
ISMP: 0★★★★−
State: 0★★★★−
Interosseous Needles: 0★★★★−
Peripheral IV – Adult: 0★★★★−
Peripheral IV – Child: 0★★★★−
Peripheral IV – Neonate: 0★★★★−
Vein Selection – Peripheral IVs: 0★★★★−
Assist with Insertion in Interventional Radiology: 0★★★★−
Catheter and Introducer Device Selection: 0★★★★−
Contraindications for Midline/PICC Placement: 0★★★★−
Correct Tip Placement: 0★★★★−
Indications for Midline/PICC Placement: 0★★★★−
Insertion Site Preparation: 0★★★★−
Insertion Technique – Basic (Vein): 0★★★★−
Insertion Technique – Seldinger: 0★★★★−
Insertion Technique – Ultrasound: 0★★★★−
Maintaining Sterile Field: 0★★★★−
Measuring Technique: 0★★★★−
Midline Catheter Insertion – Adult: 0★★★★−
Midline Catheter Insertion – Child: 0★★★★−
Repositioning After X-Ray: 0★★★★−
Securing Insertion Site Post Placement: 0★★★★−
Vein Selection: 0★★★★−
X-Ray Assessment for Tip Location: 0★★★★−
Cap Changes: 0★★★★−
Dressing Changes: 0★★★★−
Femoral Line: 0★★★★−
Flushing Lines (Frequency/Solution): 0★★★★−
Groshong CVL: 0★★★★−
Groshong PICC: 0★★★★−
Heparin/Saline Lock: 0★★★★−
Hickman/Broviac: 0★★★★−
IJ Line: 0★★★★−
Multilumen Catheters: 0★★★★−
Peripheral IV: 0★★★★−
Port-a-Cath: 0★★★★−
Power PICC: 0★★★★−
Power Port: 0★★★★−
Scalp IV: 0★★★★−
Subclavian Line: 0★★★★−
Vascath: 0★★★★−
Ativan: 0★★★★−
Chemotherapy: 0★★★★−
Fentanyl: 0★★★★−
Heparin: 0★★★★−
Lidocaine: 0★★★★−
Streptokinase: 0★★★★−
TPA (Alteplase): 0★★★★−
TPN/Lipids: 0★★★★−
Valium: 0★★★★−
Versed: 0★★★★−
Blood Warmer: 0★★★★−
CADD Pump: 0★★★★−
Curlin Pump: 0★★★★−
Needleless Systems: 0★★★★−
PCA Pumps: 0★★★★−
Pressure Lines: 0★★★★−
Rate Flow Regulator: 0★★★★−
Syringe Pump: 0★★★★−
Vista Pump: 0★★★★−
Air Embolism: 0★★★★−
Bleeding: 0★★★★−
Brachial Plexus Injury: 0★★★★−
Cardiac Arrhythmia: 0★★★★−
Cardiac Tamponade: 0★★★★−
Catheter Embolism: 0★★★★−
Catheter Erosion: 0★★★★−
Catheter Occlusion: 0★★★★−
Catheter-Related Sepsis: 0★★★★−
Catheter Tip Malposition or Retraction: 0★★★★−
Complications from Sedation: 0★★★★−
Declotting Peripheral Site: 0★★★★−
Endocarditis: 0★★★★−
Exit Site Infection: 0★★★★−
Exit Site Necrosis: 0★★★★−
Extravasation: 0★★★★−
Hematoma: 0★★★★−
Laceration of Vessels or Viscus: 0★★★★−
Myocardial Erosion: 0★★★★−
Perforation of Vessels or Viscus: 0★★★★−
Phlebitis: 0★★★★−
Repair Midline: 0★★★★−
Repair PICC: 0★★★★−
Thromboembolism: 0★★★★−
Ventricular Thrombosis: 0★★★★−
Venous Thrombosis: 0★★★★−
Vessel Erosion: 0★★★★−
Central Lines: 0★★★★−
Peripheral IVs: 0★★★★−
PICC/Midline: 0★★★★−
Please list the EMR systems you have used: