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.
Neonates < 28 Weeks 0★★★★−
Neonates 29 - 34 Weeks 0★★★★−
Neonates > 34 Weeks 0★★★★−
Level II NICU 0★★★★−
Level III NICU 0★★★★−
Level IV NICU 0★★★★−
Cardiac Surgery - Pre-op 0★★★★−
Cardiac Surgery - Immediate Post-op 0★★★★−
Congenital Heart Disease/Defects 0★★★★−
CHF/Pulmonary Edema 0★★★★−
Hemodynamic Instability 0★★★★−
Bronchopulmonary Dysplasia 0★★★★−
Diaphragmatic Hernia 0★★★★−
Fresh Tracheostomy 0★★★★−
Meconium Aspiration 0★★★★−
Persistent Pulmonary Hypertension 0★★★★−
Pneumonia 0★★★★−
Respiratory Distress Syndrome/Failure 0★★★★−
Interpretation of ABGs 0★★★★−
Assist with Intubation/Extubation 0★★★★−
Endotracheal Suctioning 0★★★★−
Chest Tube Placement and Management 0★★★★−
Modes of Ventilation (AC/PC/SIMV/CPAP/BiPAP) 0★★★★−
High Frequency Ventilation 0★★★★−
Inhaled NO 0★★★★−
ECMO 0★★★★−
Ballard/Dubowitz 0★★★★−
Reflexes Based on Gestational Age 0★★★★−
Hydrocephalus 0★★★★−
Intraventricular Hemorrhage 0★★★★−
Meningocele/Myelomeningocele 0★★★★−
Neonatal Abstinence Score/Syndrome 0★★★★−
Seizures 0★★★★−
Colostomy/Ileostomy 0★★★★−
Gastroschisis/Omphalocele 0★★★★−
GI Bleeding 0★★★★−
Necrotizing Enterocolitis 0★★★★−
Post Abdominal Procedure 0★★★★−
Breast Milk Handling/Storage 0★★★★−
Breast Pump 0★★★★−
Gavage Feedings 0★★★★−
NG/OG/NJ Tube Placement and Management 0★★★★−
Circumcision Care 0★★★★−
Genetic Disorders 0★★★★−
Hypo/Hyperglycemia 0★★★★−
Infant of Diabetic Mother 0★★★★−
Malformations of the GU Tract/Kidney 0★★★★−
Phototherapy 0★★★★−
Renal Failure 0★★★★−
Neonatal Sepsis 0★★★★−
Septic Work Up 0★★★★−
Assist with Lumbar Puncture 0★★★★−
Calculation of Neonatal Dosages 0★★★★−
Antibiotics/Antivirals 0★★★★−
Anticonvulsants 0★★★★−
Immunizations 0★★★★−
Digoxin 0★★★★−
IV Vasopressors 0★★★★−
Prostaglandin 0★★★★−
Bronchodilators 0★★★★−
Steroids 0★★★★−
Caffeine 0★★★★−
Surfactant 0★★★★−
Automated Medication Dispensing (i.e. Pyxis, Omnicell) 0★★★★−
Administration of Blood/Blood Products 0★★★★−
Central Line Catheter/Dressings 0★★★★−
Management of UAC/UVC Lines 0★★★★−
Radial Arterial Lines 0★★★★−
Start IVs 0★★★★−
Attend High Risk Deliveries 0★★★★−
Preparation for Transport 0★★★★−
Transport Neonate 0★★★★−
Rhythm Interpretation 0★★★★−
Dysrhythmia Management 0★★★★−
National Patient Safety Goals/Core Measures 0★★★★−
Bereavement/Postmortem Care 0★★★★−
Neonatal Skin Care 0★★★★−
Pressure Ulcer Risk Assessment/Prevention 0★★★★−
Restraints/Use of Least Restrictive Device 0★★★★−
Patient/Family Teaching 0★★★★−
Age Specific/Population-Based Care 0★★★★−
Isolation Precautions 0★★★★−
Infection Prevention 0★★★★−
Pain Assessment & Management 0★★★★−
Charge Experience 0★★★★−
Interpretation and Communication of Lab Values 0★★★★−
Epic 0★★★★−
Cerner 0★★★★−
Eclipsys 0★★★★−
McKesson 0★★★★−
Meditech 0★★★★−
Other Computerized System 0★★★★−
Computerized Physician Order Entry 0★★★★−
Bar Coding for Medication Administration 0★★★★−
EMR Conversion YesNo
BLS
ACLS
Telemetry Certificate
ONS Chemo/Biotherapy Certification
Other Chemo Certification
Other: Specify
