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
Communication
Organize written and oral communication in a logical manner: 0★★★★−
Question other health care professionals to collect pertinent patient information: 0★★★★−
Communicate appropriately with the level of understanding of one’s audience: 0★★★★−
Use good listening skills in all aspects of job: 0★★★★−
Interested in improving self and asks questions: 0★★★★−
Other by site: 0★★★★−
Patient Interaction / Staff Relations
Greets patient and introduces self: 0★★★★−
Puts others at ease: 0★★★★−
Interview patient or caregiver to collect pertinent patient information: 0★★★★−
Use different strategies for communicating with non-English speakers or impaired patients: 0★★★★−
Exhibit empathy and compassion: 0★★★★−
Cooperation / Diplomacy and Tact with Staff: 0★★★★−
Emotional Maturity to Function Under Stress: 0★★★★−
Appropriate Conversation with Staff/Patients: 0★★★★−
Use of Correct Terminology: 0★★★★−
Sensitivity to Patient Comfort: 0★★★★−
Personal Characteristics
Problem solve in the workplace to better a situation: 0★★★★−
Adaptable to change; industrious: 0★★★★−
Ability to learn and retain information: 0★★★★−
Sufficient speed in completing tasks: 0★★★★−
Ability to adapt to new procedures: 0★★★★−
Displays initiative: 0★★★★−
Demonstrate ethical behavior with emphasis on confidentiality and protocols: 0★★★★−
Maintain emotional stability under stress: 0★★★★−
Accept direction and guidance from supervisor/faculty: 0★★★★−
Understands differing facility procedures and adapts easily: 0★★★★−
Arrives for shift on time / punctual: 0★★★★−
Undertaking appropriate & additional duties: 0★★★★−
Maintains impeccable personal hygiene & professional appearance: 0★★★★−
Anticipates doctor’s/co-worker needs: 0★★★★−
Neatness in accomplishing work: 0★★★★−
Essential Job Functions
Collect pertinent patient information for pharmacist: 0★★★★−
Locate specific information from medical record/electronic device: 0★★★★−
Understand pharmacist needs to manage pharmacy services: 0★★★★−
Demonstrate proficiency with word processing and database software: 0★★★★−
Use internet, email, and medication databases: 0★★★★−
Follow procedure for purchasing pharmaceuticals, devices, and supplies: 0★★★★−
Understand and comply with State/Federal laws: 0★★★★−
Compound sterile and non-sterile products: 0★★★★−
Prepare an IV admixture: 0★★★★−
Observe or prepare a TPN order: 0★★★★−
Suggest alternative sources for unavailable products: 0★★★★−
Understand pricing and product alternatives: 0★★★★−
Know proper storage conditions for pharmaceuticals: 0★★★★−
Return expired, damaged or recalled pharmaceuticals: 0★★★★−
Prevent and report medication errors: 0★★★★−
Inventory and maintain records for controlled substances: 0★★★★−
Screen medication orders/prescriptions for completeness: 0★★★★−
Create new patient profile: 0★★★★−
Enter information accurately into computer for label and MAR: 0★★★★−
Accurately prepare medication order/prescription: 0★★★★−
Dispose of hazardous materials/waste: 0★★★★−
Prepare and label repackaged products: 0★★★★−
Process reimbursement claim forms: 0★★★★−
Sterilize a laminar or horizontal air flow hood: 0★★★★−
Efficiently deliver the correct medication: 0★★★★−
Know policies for distribution of medications/controlled substances: 0★★★★−
Know patient consultation limits for technician: 0★★★★−
Handle third party rejection claims: 0★★★★−
Work a cash register: 0★★★★−
Reconstitute a granular antibiotic into suspension form: 0★★★★−
Prepare, store and distribute investigational drug products: 0★★★★−
Obtain technician licensure and certification: 0★★★★−
Determine patient eligibility and co-pay: 0★★★★−
Calibrate a device: 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★★★★−
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