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
Outpatient
Inpatient
Rehab
Adult
Pediatric
Electroencephalogram (EEG)
Brain Death Study
Electromyogram (EMG)
Nerve Conduction Studies
Somatosensory Evoked Potentials (SSEP)
Visual Evoked Response (VER)
Auditory Evoked Response (AER)
Brain Stem Auditory Evoked Response (BAER)
Head & Neck Vascular Ultrasound Interpretation
Sleep Studies
Lumbar Puncture - Adult
Lumbar Puncture – Pediatric
Subdural Taps
Thrombolytic Therapy
Muscle Biopsy
Peripheral Nerve Biopsy
Temporal Artery Biopsy
Intrathecal Administration of Medication
Arterial Lines
Central Venous Lines
Swan-Ganz Catheterization
Disability Evaluations
Traumatic Brain Injury
Spinal Cord Injury
Stroke
Neuromuscular Disorders
Sleep Disorders
Peripheral Nerve Blocks
Spinal / Paraspinal blocks
Epidural Blocks
Transcranial Doppler
Deep Brain Stimulation (DBS)
Intraoperative Microelectrode Recording
Botulinum Toxin Injection
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.
