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
Work Settings
Acute care: 0★★★★−
Children's hospital: 0★★★★−
Daily treatment center: 0★★★★−
Home health care: 0★★★★−
Inpatient acute rehab: 0★★★★−
Neonatal intensive care: 0★★★★−
Outpatient/outpatient community re-entry: 0★★★★−
Pediatrics: 0★★★★−
Psychiatric hospital: 0★★★★−
Private practice: 0★★★★−
School setting: 0★★★★−
Early intervention: 0★★★★−
Skilled nursing facility: 0★★★★−
Patient Populations
Geriatrics: 0★★★★−
Hearing impaired: 0★★★★−
Learning disabilities: 0★★★★−
Pediatrics/school age: 0★★★★−
Progressive neurologic disease: 0★★★★−
Trachs/ventilators: 0★★★★−
Transient Ischemic Attach (TIA): 0★★★★−
Traumatic brain injury: 0★★★★−
Voice/laryngectomy: 0★★★★−
Assessment Tools
Boston assessment of severe aphasia: 0★★★★−
Boston diagnostic aphasia examination: 0★★★★−
Minnesota test for differential diagnosis of aphasia: 0★★★★−
Informal testing: 0★★★★−
Porch index of communicative abilities: 0★★★★−
Reading comprehension battery for aphasia: 0★★★★−
Ross information processing assessment-geriatric: 0★★★★−
Western aphasia battery: 0★★★★−
Bedside swallow evaluation: 0★★★★−
Blue dye test: 0★★★★−
Cervical auscultation: 0★★★★−
Fiber endoscopic evaluation study: 0★★★★−
Modified barium swallow study: 0★★★★−
Rehab Institute of Chicago evaluation of communication: 0★★★★−
Augmentative devices: 0★★★★−
Pure tone screening: 0★★★★−
Types of Disorders
Aphasia: 0★★★★−
Apraxia: 0★★★★−
Autism: 0★★★★−
Cleft palate: 0★★★★−
CVA/stroke: 0★★★★−
Fluency: 0★★★★−
Dementia/alzheimers: 0★★★★−
Dysarthria: 0★★★★−
Dysphagia: 0★★★★−
Hearing loss: 0★★★★−
Treatment
Behavior modification: 0★★★★−
Cognitive training: 0★★★★−
Community re-entry: 0★★★★−
Computer: 0★★★★−
Co-treatment: 0★★★★−
Group: 0★★★★−
Individual: 0★★★★−
Safety awareness: 0★★★★−
Total communication: 0★★★★−
Vital stimulation: 0★★★★−
Dysphagia across the age-spectrum: 0★★★★−
Regulations
FIMS: 0★★★★−
Medi-Cal: 0★★★★−
Medicare: 0★★★★−
Omnibus budget reconciliation: 0★★★★−
RUG levels: 0★★★★−
General Skills
Patient/family teaching: 0★★★★−
Patients in isolation: 0★★★★−
Patients in restraints: 0★★★★−
Initial evaluation: 0★★★★−
Lift/transfer devices: 0★★★★−
Specialty beds: 0★★★★−
End of life care/palliative care: 0★★★★−
Computerized Charting:
Cerner: 0★★★★−
EPIC: 0★★★★−
McKesson: 0★★★★−
Meditech: 0★★★★−
National Patient Safety Goals:
Accurate patient identification: 0★★★★−
Effective communication: 0★★★★−
Pain assessment & management: 0★★★★−
Infection control: 0★★★★−
Universal precautions: 0★★★★−
Care of patients in isolation: 0★★★★−
Minimize risk of falls: 0★★★★−
Prevention of pressure ulcers: 0★★★★−
Age Specific Competencies
Infant (birth to 1 year): 0★★★★−
Toddler (ages 1-3 years): 0★★★★−
Preschooler (ages 3-5 years): 0★★★★−
Childhood (ages 6-12 years): 0★★★★−
Adolescents (ages 12-21 years): 0★★★★−
Young Adults (ages 21-39 years): 0★★★★−
Adults (ages 40-64 years): 0★★★★−
Older Adults (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
Please list any Additional Skills
Additional training:
Additional equipment:
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