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
Areas Worked
Emergency: 0★★★★−
Urgent Care: 0★★★★−
Private Practice: 0★★★★−
HMO: 0★★★★−
MD Office: 0★★★★−
Schools: 0★★★★−
Health Department: 0★★★★−
Ambulatory Clinic: 0★★★★−
Rural Health Clinic: 0★★★★−
Psychiatric Facility: 0★★★★−
Correctional Facility: 0★★★★−
Mobile Medical Unit: 0★★★★−
Corporate Worksite: 0★★★★−
Occupational Health: 0★★★★−
Rehabilitation: 0★★★★−
Nursing Home/Long-term Care Facility: 0★★★★−
Women's Health Clinic: 0★★★★−
Government Health Agency: 0★★★★−
Hospice/Palliative Care: 0★★★★−
Experience With
Diabetes: 0★★★★−
Contractures: 0★★★★−
Bedridden Residents: 0★★★★−
Splinting of Extremities: 0★★★★−
Local Infiltration: 0★★★★−
Comprehensive Physical Assessment: 0★★★★−
Acute Disease Condition: 0★★★★−
Differential Diagnosis: 0★★★★−
Order, Perform & Interpret Screening and Diagnostic Test: 0★★★★−
Central Line Management: 0★★★★−
Disorders – Emergencies
Anaphylaxis: 0★★★★−
Cardiac Arrest: 0★★★★−
Seizures: 0★★★★−
Minor Head Injuries: 0★★★★−
Animal Bites: 0★★★★−
Ingestions and Poisonings: 0★★★★−
Overdose of Sedatives, Hypnotics, Opiates: 0★★★★−
Snake Bites: 0★★★★−
Minor Burns: 0★★★★−
Shock: 0★★★★−
Open Wounds: 0★★★★−
Collaboration
Family, Support System, Community Resources: 0★★★★−
Consulting with Physicians: 0★★★★−
Consulting with Pharmacists: 0★★★★−
Consulting with Speech Therapist: 0★★★★−
Consulting with Dietician and Diet Aide: 0★★★★−
Consulting with Occupational Therapist: 0★★★★−
Referral to Pastoral Services: 0★★★★−
Respiratory
Croup: 0★★★★−
Influenza: 0★★★★−
Tracheobronchitis: 0★★★★−
Bronchitis: 0★★★★−
COPD (Chronic Obstructive Pulmonary Disease): 0★★★★−
Asthma: 0★★★★−
URI (Upper Respiratory Infection): 0★★★★−
Obstructive Sleep Apnea: 0★★★★−
Pneumonia:
Viral: 0★★★★−
Bacterial: 0★★★★−
Sinusitis:
Nonbacterial: 0★★★★−
Oxygen Administration: 0★★★★−
Liquid Oxygen: 0★★★★−
IPPB Machine Use: 0★★★★−
Tracheotomies: 0★★★★−
Interpret ABG (Blood Gases): 0★★★★−
Intubations: 0★★★★−
Sputum Collection: 0★★★★−
Cardiovascular System
Congestive Heart Failure: 0★★★★−
Chronic Obstructive Pulmonary Disease: 0★★★★−
Stasis Ulcer of Lower Extremities: 0★★★★−
Angina: 0★★★★−
Pericarditis: 0★★★★−
Coronary Artery Disease: 0★★★★−
Functional Murmurs: 0★★★★−
Congenital Heart Disease: 0★★★★−
Hypertension: 0★★★★−
ASHD (Arteriosclerotic Heart Disease): 0★★★★−
Dyslipidemia: 0★★★★−
PVD (Peripheral Vascular Disease): 0★★★★−
Peripheral Neuropathy: 0★★★★−
Interpreting 12 Lead EKG's: 0★★★★−
OB/GYN
Candida Vaginitis: 0★★★★−
Dysmenorrhea: 0★★★★−
Abnormal Pap Smear Findings: 0★★★★−
Pap Smears: 0★★★★−
Trichomonal Vaginitis: 0★★★★−
Atrophic Vaginitis: 0★★★★−
Fibrocystic Breast Disease: 0★★★★−
Menopause: 0★★★★−
Intrapartum Medications: 0★★★★−
Bartholin's Cyst/Abscess: 0★★★★−
Preparation for Childbirth: 0★★★★−
Pregnancy - Diagnosis and Referral: 0★★★★−
Pain Relief in Active Phase of Labor: 0★★★★−
Medications in the Third Stage: 0★★★★−
Dysfunctional Uterine Bleeding: 0★★★★−
Medications in the Postpartum Phase: 0★★★★−
Rh Blood Factor: 0★★★★−
Mastitis: 0★★★★−
Birth Control Methods: 0★★★★−
Prenatal Care: 0★★★★−
Fetal Well-being: 0★★★★−
Nausea and Vomiting with Pregnancy: 0★★★★−
Pregnancy Test Kits: 0★★★★−
GI System
Constipation: 0★★★★−
Diarrhea (Simple): 0★★★★−
Acute Gastroenteritis: 0★★★★−
Cholecystitis: 0★★★★−
Pyloric Stenosis: 0★★★★−
Colic: 0★★★★−
Appendicitis: 0★★★★−
Naso-gastric Tubes: 0★★★★−
Gastrostomy Care: 0★★★★−
Skin
Warts: 0★★★★−
Basal Cell Carcinoma: 0★★★★−
Scabies: 0★★★★−
Impetigo: 0★★★★−
Diaper Dermatitis: 0★★★★−
Acne: 0★★★★−
Folliculitis: 0★★★★−
Furuncles: 0★★★★−
Carbuncles: 0★★★★−
Herpes Simplex: 0★★★★−
Herpes Zoster: 0★★★★−
Malignant Melanoma: 0★★★★−
Pityriasis Rosea: 0★★★★−
Contact Dermatitis: 0★★★★−
Tinea Corporis: 0★★★★−
Tinea Pedis: 0★★★★−
Staph Infections: 0★★★★−
Wound Care: 0★★★★−
Single Layer Wound Closure: 0★★★★−
Incision and Drainage: 0★★★★−
Excisions: 0★★★★−
Ears, Nose and Throat
Epistaxis: 0★★★★−
Otitis Externa: 0★★★★−
Serous Otitis Media: 0★★★★−
Acute Purulent Otitis Media: 0★★★★−
Allergic Rhinitis: 0★★★★−
Pharyngitis: 0★★★★−
Oral Candidiasis: 0★★★★−
Eye
Conjunctivitis: 0★★★★−
Strabismus: 0★★★★−
Chalazion: 0★★★★−
Stye: 0★★★★−
Visual Acuity: 0★★★★−
Fluorescein Staining of Eyes: 0★★★★−
Audiometry: 0★★★★−
Tympanometry: 0★★★★−
Musculoskeletal
Osteoporosis: 0★★★★−
Osteomyelitis: 0★★★★−
Rheumatoid Arthritis: 0★★★★−
Juvenile Diabetes: 0★★★★−
Gout: 0★★★★−
Minor Sprains and Strains: 0★★★★−
Osteoarthritis: 0★★★★−
Carpal Tunnel Syndrome: 0★★★★−
Scoliosis: 0★★★★−
Tendonitis: 0★★★★−
Bursitis: 0★★★★−
Muscular Dystrophy: 0★★★★−
Parasitic Infections
Pinworms: 0★★★★−
Ascariasis: 0★★★★−
Pediculosis: 0★★★★−
Genitourinary System
Syphilis: 0★★★★−
Chlamydia: 0★★★★−
Herpes: 0★★★★−
Cystitis: 0★★★★−
Pyelonephritis: 0★★★★−
Urinary Tract Infection: 0★★★★−
Benign Prostatic Hypertrophy: 0★★★★−
Vulvovaginitis: 0★★★★−
Hypospadias: 0★★★★−
Hydrocele: 0★★★★−
Gonococcal Infections: 0★★★★−
Prostatitis: 0★★★★−
Catheter Care: 0★★★★−
Incontinence Care-Bowel: 0★★★★−
Dermal Ulcers: 0★★★★−
Enemas/Suppositories/Fecal: 0★★★★−
Urine Collection: 0★★★★−
Nervous System
Vasovagal Syncope: 0★★★★−
Migraine Headaches: 0★★★★−
Multiple Sclerosis: 0★★★★−
Headaches: 0★★★★−
Head Injury: 0★★★★−
Tension: 0★★★★−
Anxiety: 0★★★★−
Parkinson's: 0★★★★−
Alzheimer's: 0★★★★−
Bell's Palsy: 0★★★★−
TIA (Transient Ischemic Attacks): 0★★★★−
Trigeminal Neuralgia: 0★★★★−
Endocrine
Type I Diabetes Mellitus: 0★★★★−
Type II Diabetes Mellitus: 0★★★★−
Graves Disease: 0★★★★−
Addison's Disease: 0★★★★−
Hypoglycemia: 0★★★★−
Hypothyroidism: 0★★★★−
Hematological
Folic Acid Deficiency Anemia: 0★★★★−
Aplastic Anemia: 0★★★★−
Iron Deficiency: 0★★★★−
Sickle Cell Anemia: 0★★★★−
Pernicious Anemia: 0★★★★−
Hemoglobinometer: 0★★★★−
Psychosocial
Depression: 0★★★★−
Suicide: 0★★★★−
Obesity: 0★★★★−
Grief: 0★★★★−
Anorexia: 0★★★★−
Bulimia: 0★★★★−
Drug Therapy
Prescription: 0★★★★−
Over the Counter (OTC): 0★★★★−
Herbal Drugs: 0★★★★−
Knowledge of Pharmacology: 0★★★★−
Knowledge of Pharmacokinetics: 0★★★★−
Knowledge of Drug Interactions: 0★★★★−
Knowledge of Side Effects: 0★★★★−
Knowledge of Potential Adverse Reactions:
Allergic Reactions: 0★★★★−
Anaphylaxis Reaction: 0★★★★−
TPN/Lipid Management: 0★★★★−
Management/Titration of IV Therapies: 0★★★★−
IV/PO Antibiotic Therapy and Understanding of Cultures: 0★★★★−
Dispensing Medication
Monitoring Drug Therapy: 0★★★★−
Management of Controlled Substances: 0★★★★−
Injections: 0★★★★−
Non-Pharmacologic Interventions
Medical Nutrition Therapy: 0★★★★−
Exercise: 0★★★★−
Cessation of Substance Abuse (Alcohol, Tobacco): 0★★★★−
Mental Health Issues (Stress Management, Depression): 0★★★★−
Obesity Management: 0★★★★−
Tube Feeding Management: 0★★★★−
Miscellaneous
Public Health and Health Promotion: 0★★★★−
Research: 0★★★★−
Quality Assurance: 0★★★★−
Leadership and Teaching Skills: 0★★★★−
Legal and Ethical Issues: 0★★★★−
Confidentiality: 0★★★★−
Cultural Awareness: 0★★★★−
Self Evaluation to Improve Patient Care: 0★★★★−
Continuing Education: 0★★★★−
Working Within Scope of Practice: 0★★★★−
Discharge Planning/Collaboration: 0★★★★−
Suturing: 0★★★★−
Cell Biopsy: 0★★★★−
Starting IV: 0★★★★−
Casting and Splinting: 0★★★★−
Radiographic Interpretation (Initial): 0★★★★−
Informed Consent: 0★★★★−
Explanation to Patient/Family: 0★★★★−
Documentation: 0★★★★−
Venipuncture: 0★★★★−
Ultrasounds: 0★★★★−
Programs
OSHA (Occupational Safety and Health Administration): 0★★★★−
Medicare and Medicaid: 0★★★★−
CLIA Waiver (Clinical Laboratory Improvement Amendments): 0★★★★−
TJC (The Joint Commission): 0★★★★−
HEDIS (Health Plan Employer Data and Information Set): 0★★★★−
DQIP (Diabetes Quality Improvement Program): 0★★★★−
HIPAA (Health Insurance Portability & Accountability Act): 0★★★★−
HCAHPS: 0★★★★−
Age Specific Competencies
Newborn/Neonate (Birth-30 Days): 0★★★★−
Infant (31 Days-1 Year): 0★★★★−
Toddler (Ages 2-3 Years): 0★★★★−
Preschool (Ages 4-5 Years): 0★★★★−
School Age (Ages 6-12 Years): 0★★★★−
Adolescents (Ages 13-21 Years): 0★★★★−
Young Adult (Ages 22-39 Years): 0★★★★−
Adults (Ages 40-64 Years): 0★★★★−
Older Adult (Ages 65-79 Years): 0★★★★−
Elderly (Ages 80+ Years): 0★★★★−
Please list any Additional Skills
Additional training:
Additional equipment:
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