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
Universal Protocol
Crash Cart/Defibrillator
Patient Identification
Hand-off Communication
Standard Precautions
Isolation Precautions
Respiratory/Cardiac Arrest
Electronic Documentation
Cesarean Section
Dilation & Curettage
Hysterectomy - Vaginal
Hysterectomy - Laparoscopic
Laser Surgery
Radium Insertion
Salpingo- Oopherectomy
Shirodkar Procedure
Termination of Pregnancy
Tubal Ligation
Vaginectomy
Vaginal Reconstruction
Robotics
Electocautery
Log
Biological Indicators
Autoclave Operation
High Level
STERIS
Steam
Gas
Flash
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)
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.
