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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
IV Therapy
Start peripheral IV - angio cath: 0★★★★−
IV Therapy - Assist with
Insertion of A-lines: 0★★★★−
Insertion of CVP - jugular: 0★★★★−
Insertion of CVP - sublavian: 0★★★★−
Insertion of Swan-Ganz: 0★★★★−
Drawing blood from central line: 0★★★★−
Drawing venous blood: 0★★★★−
Administration of blood and products
Packed red blood cells: 0★★★★−
Plasma/Albumin: 0★★★★−
Whole blood: 0★★★★−
General Surgery
Abdominal perineal resection: 0★★★★−
Adrenalectomy: 0★★★★−
Anal fissurectomy: 0★★★★−
Appendectomy: 0★★★★−
Bowel resection: 0★★★★−
Breast biopsy: 0★★★★−
Cholecystectomy (open): 0★★★★−
Colectomy: 0★★★★−
Colostomy/ileostomy: 0★★★★−
Esophogeal resection: 0★★★★−
Exploratory laparotomy: 0★★★★−
Gastrectomy: 0★★★★−
Gastroplasty: 0★★★★−
Hemorrhoidectomy: 0★★★★−
Hemicolectomy: 0★★★★−
Hepatic resection: 0★★★★−
Herniorrhaphy - femora: 0★★★★−
Herniorrhaphy - inguina: 0★★★★−
Herniorrhaphy - umbilical: 0★★★★−
Herniorrhaphyhiatal transabdominal/transthoracic: 0★★★★−
Hiatal hernia repair: 0★★★★−
Insertion - Hickman: 0★★★★−
Insertion - Groshong: 0★★★★−
Insertion - Portacath: 0★★★★−
Hydroceletomy: 0★★★★−
Imperforate anus reconstruction: 0★★★★−
Lumbar sympathectomy: 0★★★★−
Omphalocele repair: 0★★★★−
Pancreatectomy / pancreatogram: 0★★★★−
Pilonidal cystectomy: 0★★★★−
Portal caval shunt: 0★★★★−
Pyloric stenosis: 0★★★★−
Radical mastectomy: 0★★★★−
Saphenous vein ligation and stripping: 0★★★★−
Sentinel node biopsy: 0★★★★−
Splenectomy: 0★★★★−
Tenchknoff duct cyst excision: 0★★★★−
Thyroglossal duct cyst excision: 0★★★★−
Thryoidectomy: 0★★★★−
Vagotomy: 0★★★★−
Thoracic and Open Heart
Cervical rib excision: 0★★★★−
Chamberlain procedure: 0★★★★−
Closed thoracotomy: 0★★★★−
Correction pectus excavatum: 0★★★★−
Esophagectomy: 0★★★★−
Heller procedure: 0★★★★−
Mitral commissurotomy: 0★★★★−
Mitral or aortic valve replacement: 0★★★★−
IAPB insertion: 0★★★★−
CABG: 0★★★★−
Cardiac valve replacement: 0★★★★−
Patent ductus arteriosus repair: 0★★★★−
Septal defect repairs: 0★★★★−
Pacemaker implanation - endocardial: 0★★★★−
Pacemaker implanation - myocardia: 0★★★★−
Pacemaker - temporary: 0★★★★−
Pericardiectomy: 0★★★★−
Pericardial window: 0★★★★−
Resection coarctation aorta: 0★★★★−
Portocaval shunt: 0★★★★−
Tetrology of fallot: 0★★★★−
Thoracoplasty: 0★★★★−
Tracheal resection: 0★★★★−
Transthoracic diaphragmatic heniorrhaphy: 0★★★★−
Vascular
A-V access graft: 0★★★★−
Aortic aneurysm with graft replacement: 0★★★★−
Endarterectomy/carotid - femoral: 0★★★★−
Fem-pop bypass: 0★★★★−
Peripheral vascular bypass procedures: 0★★★★−
Resection carotid aneurysm with graft: 0★★★★−
Thrombectomy/embolectomy: 0★★★★−
Vena cava filter/umbrella: 0★★★★−
Vena cava ligation: 0★★★★−
Neurology
A-V malformation: 0★★★★−
Anterior cervical fusion: 0★★★★−
Anterior laparoscopic spine procedures: 0★★★★−
Anterior lumbar interbody fusion (ALIF): 0★★★★−
Burr holes for subdural hematoma: 0★★★★−
Carotid ligation: 0★★★★−
Cervical sympathectomy: 0★★★★−
Craniectomy for decompression fracture: 0★★★★−
Discetomy: 0★★★★−
Hypophysectomy: 0★★★★−
Insertion nerve stimulators: 0★★★★−
Insertion medication pumps: 0★★★★−
Laminectomy: 0★★★★−
Myelomeningocele repair: 0★★★★−
Pedicle screw insertion: 0★★★★−
Posterior lumbar interbody fusion (PLIF): 0★★★★−
Shunt procedure/VP, VA/LP: 0★★★★−
Spine fusion: 0★★★★−
Ulnar nerve transfer: 0★★★★−
Ventriculography / ventriculoscopy: 0★★★★−
Ventriculostomy: 0★★★★−
Neurology - Cranioplasty/craniotomy
Clipping of aneurysm: 0★★★★−
Tumor excision: 0★★★★−
Stealth crainiotomy: 0★★★★−
Urology
Adult circumcision: 0★★★★−
Cystectomy: 0★★★★−
Cystoscopy/ureteroscopy: 0★★★★−
Hypospadias repair: 0★★★★−
Ileal loop: 0★★★★−
Implants - penile and testicular: 0★★★★−
Lithotripsy: 0★★★★−
Nephrectomy: 0★★★★−
Nephrolithotomy: 0★★★★−
Orchiopexy: 0★★★★−
Prostatectomy - perineal: 0★★★★−
Prostatectomy - supra-pubic: 0★★★★−
Pyleoplasty: 0★★★★−
Radical node dissection: 0★★★★−
Scott incontinence device: 0★★★★−
TURP: 0★★★★−
Ureterolithotomy: 0★★★★−
Vasectomy: 0★★★★−
Vasovasostomy: 0★★★★−
Waterhouse procedure: 0★★★★−
Gynecology
Cesarean section: 0★★★★−
Colpotomy: 0★★★★−
Dilation and curettage (DandC): 0★★★★−
Hysterectomy - abdominal: 0★★★★−
Hysterectomy - vaginal: 0★★★★−
Marshall - Marchetti: 0★★★★−
Marsupialization, Bartholin cyst: 0★★★★−
Ovarian cystectomy: 0★★★★−
Radium insertion: 0★★★★−
Salpingo-oophorectomy: 0★★★★−
Sacral spinus fixation: 0★★★★−
Shirodkar procedure: 0★★★★−
Suction curettage: 0★★★★−
Termination of pregnancy: 0★★★★−
Tubal ligation: 0★★★★−
Vaginal recontruction: 0★★★★−
Vaginectomy/vulvectomy: 0★★★★−
Orthopedics
Acetabular/pelvic ORIF: 0★★★★−
Achilles tendon repair: 0★★★★−
Amputation- leg, arm: 0★★★★−
Anterior cruciate ligament repair: 0★★★★−
Application of external fixators - extremeties: 0★★★★−
Application of external fixators - pelvis: 0★★★★−
Application of halo traction: 0★★★★−
Arthrotomy: 0★★★★−
Bipolar/unipolar hips: 0★★★★−
Bunionectomy: 0★★★★−
Calcanel reconstruction: 0★★★★−
Capsulorrhaphy: 0★★★★−
Carpal tunnel release: 0★★★★−
Closed reduction fracture: 0★★★★−
Hand surgery with implants: 0★★★★−
Harrington rod instrumentation and / or Dwyer procedure: 0★★★★−
Heel cord lengthening: 0★★★★−
Olecranon bursa, excision of: 0★★★★−
ORIF, internal fixation with compression set: 0★★★★−
Patellectomy: 0★★★★−
PuttiPlatt/Bankart procedure/rotator cuff repair: 0★★★★−
Reduction with compression sets: 0★★★★−
Reimplanation of digits: 0★★★★−
Repair hammer toes: 0★★★★−
Sacro-iliac (SI) joint screws: 0★★★★−
Sharrard procedure: 0★★★★−
Spica cast, application: 0★★★★−
Spinal fusion: 0★★★★−
Tendon transplants (hand and foot): 0★★★★−
Orthopedics - Arthroscopy
Ankle: 0★★★★−
Elbow: 0★★★★−
Knee: 0★★★★−
Shoulder: 0★★★★−
Orthopedics - Hip compression nails and lag screws
Jewett: 0★★★★−
Kuntscher rod: 0★★★★−
Lottes: 0★★★★−
Rush: 0★★★★−
Schneider: 0★★★★−
Zimmer: 0★★★★−
Iliac crest bone graft: 0★★★★−
Insertion Austin Moore hip prosthesis: 0★★★★−
Orthopedics - Intramedullary rods
Extraction: 0★★★★−
Femoral: 0★★★★−
Humeral: 0★★★★−
Insertion: 0★★★★−
Supracondylar: 0★★★★−
Tibal: 0★★★★−
Orthopedics - Total joint replacements/revisions
Hip: 0★★★★−
Plastics
Abdominal lipectomy: 0★★★★−
Abdominalplasty: 0★★★★−
Blepharoplasty: 0★★★★−
Cleft lip repair: 0★★★★−
Dermabrasion: 0★★★★−
Face lift: 0★★★★−
Mentoplasty: 0★★★★−
Otoplasty: 0★★★★−
Pedicle grafts: 0★★★★−
Rhytidectomy: 0★★★★−
Scar revisions: 0★★★★−
Split thickness skin grafting: 0★★★★−
Tissue expanders: 0★★★★−
Plastics - Mammoplasty
Augmentation: 0★★★★−
Reduction: 0★★★★−
Tramflaps with reconstructive mammoplasty: 0★★★★−
Ear, Nose and Throat
Adenoidectomy: 0★★★★−
Caldwell - Luc: 0★★★★−
Cleft lip/palate repair: 0★★★★−
Closed reduction nasal fx: 0★★★★−
Ethmoidectomy: 0★★★★−
Excision of salivary gland tumor: 0★★★★−
Fenestration procedure: 0★★★★−
Frontal flap sinus procedure: 0★★★★−
Glossectomy: 0★★★★−
Laryngectomy: 0★★★★−
Mandibulectomy: 0★★★★−
Mastoidectomy: 0★★★★−
Maxillary advancement with graft: 0★★★★−
Maxillectomy: 0★★★★−
Myringoplasty: 0★★★★−
Myringotomy with PE tube insertion: 0★★★★−
Nasal polypectomy: 0★★★★−
Open reducation facial fx: 0★★★★−
Open reducation nasal fx: 0★★★★−
Parotidectomy: 0★★★★−
Pharyngeal flap procedure: 0★★★★−
Radical neck dissection: 0★★★★−
Ranulectomy: 0★★★★−
Rhinoplasty/septoplasty: 0★★★★−
Selective osteotomy of maxilla/mandible: 0★★★★−
Sinus endoscopy: 0★★★★−
Sinusotomy: 0★★★★−
Stapedectomy: 0★★★★−
Submucous resection: 0★★★★−
Tonsillectomy: 0★★★★−
Tracheostomy: 0★★★★−
Tympanoplasty: 0★★★★−
Oral
Closed reducation facial fractures/wiring: 0★★★★−
Excision odontoma: 0★★★★−
Excision of deciduous teeth: 0★★★★−
Extraction of impacted molars: 0★★★★−
Fractured jaws, mandibular and zagomatic: 0★★★★−
Ginivectomy: 0★★★★−
LeFort osteotomies: 0★★★★−
Maxillary procedure with graft: 0★★★★−
Pediatric dentistry: 0★★★★−
Sagittal osteotomy: 0★★★★−
Temporomandibular (TMJ) with arthroplasty: 0★★★★−
TMJ exploration: 0★★★★−
Ophthalmology
Cataract extraction with IOL: 0★★★★−
Corneal transplant: 0★★★★−
Dacryocystectomy: 0★★★★−
Eye enucleation: 0★★★★−
Exicison of chalazion: 0★★★★−
Canthotomy: 0★★★★−
Correction of ectropian/entropian: 0★★★★−
Enucleation: 0★★★★−
Eye transplant: 0★★★★−
Iridectomy: 0★★★★−
Lacrimal duct probing: 0★★★★−
Lid and muscle procedures: 0★★★★−
Orbital implant: 0★★★★−
Phaco emulsification: 0★★★★−
Ptergium repair: 0★★★★−
Recession resection: 0★★★★−
Refractive keratoplasty: 0★★★★−
Repair orbital blowout fracture: 0★★★★−
Repair of retinal detachment: 0★★★★−
Scleral buckle: 0★★★★−
Vitrectomy: 0★★★★−
Endoscopic Procedures
Bronchoscopy: 0★★★★−
Colonscopy: 0★★★★−
Culdoscopy: 0★★★★−
Esophagoscopy: 0★★★★−
Gastroscopy: 0★★★★−
Hysteroscopy: 0★★★★−
Laparoscopic procedures
Cholecystectomy / cholangiogram: 0★★★★−
Colon resection: 0★★★★−
Diagnostic: 0★★★★−
Hernia repair: 0★★★★−
Nissen fundoplication: 0★★★★−
Vaginal hysterectomy: 0★★★★−
Larynoscpy and microlaryngoscopy: 0★★★★−
Mediastinoscopy: 0★★★★−
Pelviscopy: 0★★★★−
Sigmoidoscopy: 0★★★★−
Thoracoscopy: 0★★★★−
Transplant
Bone: 0★★★★−
Bone marrow: 0★★★★−
Harvesting: 0★★★★−
Heart: 0★★★★−
Kidney: 0★★★★−
Liver: 0★★★★−
Lung: 0★★★★−
Multi-organ: 0★★★★−
Pancreas: 0★★★★−
Skin: 0★★★★−
Trauma
Burns: 0★★★★−
Motor vehile accidents (multiple injuries): 0★★★★−
Traumatic amputations: 0★★★★−
Trauma - Gunshot/stab wounds
Abdomen: 0★★★★−
Chest: 0★★★★−
Head: 0★★★★−
Equipment
Argon beam coagulator: 0★★★★−
Bair hugger: 0★★★★−
Blood/fluid warmer: 0★★★★−
Cardiac monitor and pacemaker: 0★★★★−
Cell saver: 0★★★★−
Cidex soak: 0★★★★−
Cry-opthalmic unit: 0★★★★−
Defibrillator/pacer: 0★★★★−
Electrosurgical unit: 0★★★★−
Emerson thoracic pump: 0★★★★−
ETO sterilizer: 0★★★★−
Eye magnet: 0★★★★−
Fiber optic luminator: 0★★★★−
Flash autoclave: 0★★★★−
Hypo/hyperthemia units: 0★★★★−
Kreiselman resuscitor: 0★★★★−
Mesh graft: 0★★★★−
Microscopes: 0★★★★−
Nerve stimulator: 0★★★★−
Nitrous oxide bank: 0★★★★−
Ohio suction units: 0★★★★−
Orthopedic arm board with drain: 0★★★★−
Pleurevac disp. chest drainage: 0★★★★−
Pneumatic tourniquet: 0★★★★−
Sterad machine: 0★★★★−
Steri-vac aeratopm cabinet: 0★★★★−
Steris unit: 0★★★★−
Tele therometer: 0★★★★−
Ultrasonic cleaner: 0★★★★−
Vac-pac positioner: 0★★★★−
Vacuum curettage: 0★★★★−
Washer sanitizer: 0★★★★−
Equipment - Fracture tables
Chick/Marquet tables: 0★★★★−
Jackson table: 0★★★★−
Rush/Skytron tables: 0★★★★−
Equipment - Intestinal stapling devices
EEA: 0★★★★−
GIA: 0★★★★−
LDS: 0★★★★−
TA: 0★★★★−
Equipment - Laser
CO2: 0★★★★−
Yag: 0★★★★−
Other: 0★★★★−
Camera/video systems
Camera controller: 0★★★★−
Light source: 0★★★★−
Printers: 0★★★★−
VCRs: 0★★★★−
Dermatome
Brown: 0★★★★−
Padgett: 0★★★★−
Disposable grounding pads: 0★★★★−
Drills
3-M maxi driver: [rating 3MMAXDRI-366]
Codman craniotome: 0★★★★−
Hall air-driver: 0★★★★−
Hall dental: 0★★★★−
Hall neurotome: 0★★★★−
Midax Rex/Anspach: 0★★★★−
Minidriver: 0★★★★−
Stryker drills - large battery: 0★★★★−
Stryker drills - small battery: 0★★★★−
Surgairtome: 0★★★★−
Synthes A-O drill: 0★★★★−
Miscellaneous
Assist with intubation: 0★★★★−
Conscious sedation administration: 0★★★★−
Conscious sedation monitoring: 0★★★★−
Management of malignant hypertensive crisis: 0★★★★−
Able to assure a safe environment for the specific needs of various age groups
A.Newborn/Neonate (birth - 30 days): 0★★★★−
B.Infant (30 days - 1 year): 0★★★★−
C.Toddler (1 - 3 years): 0★★★★−
D.Preschooler (3 - 5 years): 0★★★★−
E.School age children (5 - 12 years): 0★★★★−
F.Adolescents (12 - 18 years): 0★★★★−
G.Young adults (18 - 39 years): 0★★★★−
H.Middle adults (39 - 64 years): 0★★★★−
I.Older adults (64+): 0★★★★−
Able to communicate and/or instruct patients according to their age, maturity, comprehension
Evaluate age-appropriate behavior, motor skills and physiological norms
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