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.
Couplet Care 0★★★★−
Antepartum 0★★★★−
Postpartum 0★★★★−
Newborn Nursery 0★★★★−
LDRP 0★★★★−
Vaginal Deliver 0★★★★−
Cesarian Section 0★★★★−
Anesthesia - General 0★★★★−
Anesthesia - Local 0★★★★−
Anesthesia - Spinal 0★★★★−
Bladder Distention 0★★★★−
Breast Milk Collection and Storage 0★★★★−
Breast Pump 0★★★★−
Breastfeeding - Latch Score 0★★★★−
Breastfeeding - Supplemental Feeding 0★★★★−
Breastfeeding Support 0★★★★−
Contraceptive Education 0★★★★−
Epidural/PCA 0★★★★−
Homan's Sign 0★★★★−
Multiple Births 0★★★★−
Parent/Infant Interaction/Attachment 0★★★★−
Post Partum Hemorrhage 0★★★★−
Pregnancy Induced Hypertension 0★★★★−
Tubal Ligation 0★★★★−
Amniocentesis 0★★★★−
Cardiac Disorders 0★★★★−
Diabetes 0★★★★−
Hyperemesis 0★★★★−
Multiple Gestation 0★★★★−
Non-Stress Test 0★★★★−
PIH/HELLP 0★★★★−
Placenta Previa/Abruptio 0★★★★−
Post-Trauma 0★★★★−
Pre-Term Labor/Premature Rupture of Membranes 0★★★★−
Substance Abuse 0★★★★−
FHM Interpretation and Management 0★★★★−
Fetal Assessment 0★★★★−
Labor Assessment 0★★★★−
Assist with Ultrasound 0★★★★−
Antibiotics/Antivirals 0★★★★−
Antihypertensives 0★★★★−
Antiseizure 0★★★★−
Cervical Ripening Agents 0★★★★−
Immunizations - Mother 0★★★★−
Insulin 0★★★★−
Magnesium Sulfate 0★★★★−
Methergine 0★★★★−
Opioids and Reversal Agents 0★★★★−
Pitocin 0★★★★−
Terbutaline 0★★★★−
Starting IVs 0★★★★−
IV Management 0★★★★−
Blood Product Administration 0★★★★−
Newborn Assessment 0★★★★−
Ballard Scale/Dubowitz 0★★★★−
Car Seat Education 0★★★★−
Circumcision Care/Teach to Parents 0★★★★−
Cord Care/Teach to Parents 0★★★★−
Immunizations - Infant 0★★★★−
Infant Caretaking Skills 0★★★★−
Infant Identification and Security 0★★★★−
Metabolic Screen 0★★★★−
Phototherapy 0★★★★−
Thermoregulation 0★★★★−
National Patient Safety Goals/Core Measures 0★★★★−
Experience in a "Baby Friendly" Facility 0★★★★−
Fall Risk Assessment/Prevention 0★★★★−
Pressure Ulcer Risk Assessment/Prevention 0★★★★−
Restraints/Use of Least Restrictive Device 0★★★★−
Parent/Family Teaching 0★★★★−
Age Specific/Population-Based Care 0★★★★−
Isolation Precautions 0★★★★−
Infection Prevention 0★★★★−
Reporting Communicable Diseases 0★★★★−
Pain Assessment & Management - Adult 0★★★★−
Pain Assessment & Management - Neonate 0★★★★−
Charge Experience 0★★★★−
Interpretation and Communication of Lab Values 0★★★★−
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★★★★−
Epic 0★★★★−
Cerner 0★★★★−
Eclipsys 0★★★★−
McKesson 0★★★★−
Meditech 0★★★★−
Other Computerized System
Computerized Physician Order Entry 0★★★★−
Bar Coding for Medication Administration 0★★★★−
EMR Conversion YESNo
BLS
NRP
AWHONN FHM - Intermediate
AWHONN FHM - Advanced
Lactation Consultant - IBCLC
S.T.A.B.L.E
Other: Specify:
FHM - Other Specify:
