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
Standard Precautions
Isolation Precautions
Pediatric Respiratory/Cardiac Arrest
Adult Respiratory/Cardiac Arrest
Crash Carts
Defibrillators
Electronic Documentation
Automated Med Dispensing Systems
Hospital
Independent Lab
Patient Home
Multiple Sleep Latency Test (MSLT)
Maintenance of Wakefulness Test (MWT)
Nocturnal Penile Tumescence
Seizure Study
Portable Sleep Study
Split-Night Polysomnogram
EKG Electrode Placement
EEG Electrode Placement
Seizure Hook-Up
Calibration
Patient Positioning/Preparation
Drawing Arterial Blood Gases (ABGs)
Periodic Limb Movements
Snores
Respiratory Events
Respiratory Disturbance Index (RDI)
Apnea-Hypopnea Index (AHI)
Periodic Breathing
Complex Sleep Apnea
Cheyne-Stokes
Obstructive Sleep Apnea
Hypopnea
Sleep Log
Seizure Recognition and Precaution
Transient Arousal Scoring Rules/Procedures
Oximeters
Nasal Cannula
Humidified O2
Nasal Mask
BiPAP
CPAP
Portable Set-Up
Position Sensor
Actimeter
Thermistor
Phillips Respironics
Nihon Kohden
Grass Technologies
Natus
ResMed
CleveMed
CareFusion BD
Compumedics
Cadwell
Somnomedics
Other
CPSGT
RST
RPSGT
SDS
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)
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.
