Name:
Email:
LAST 4 OF SSN:
This checklist was electronically signed on (Today’s date)
This checklist is designed to guide our client facilities in assessing your proficiency in your nursing specialty. Please use the scale provided to indicate your level of experience and expertise in each of the areas listed below.
Skill Level Indicator:
★ = No Experience
★★ = Requires Training
★★★ = Capable with Supervision
★★★★ = Capable Independently
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School Age Child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)
Standard Precautions
Isolation Precautions
Pediatric Respiratory/Cardiac Arrest
Adult Respiratory/Cardiac Arrest
Crash Carts
Defibrillators
Electronic Documentation
Automated Med Dispensing Systems
10-20 Electrode Placement
Portable Recording in Adult ICU
Portable Recording in Pediatric ICU
Portable Recording in NICU
ECI-Brain Death Recording
Ambulatory EEG
Sleep Deprived EEG
Sleep EEG
EMG
Somatosensory Evoked Potential (SSEP)
Motor Evoked Potential
Visual Evoked Potential
Auditory Evoked Potential
Assist with Nerve Conduction Studies/EMG
Paper Machine Experience
Digital Machine Experience
Nicolet
Cadwell
Grass
Xltek
Nihon Kohden
Obtain Patient History
Changes in Patient Status
Stimulation
Hyperventilation
Post Hyperventilation
Interpreting EEG Patterns
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.
