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
Single instruments
Endoscopes
Repair
Sets/ Trays
Care of instruments
Other (list):
Manual cleaning
Washer sterilizer
Soiled linen
Disinfectants
Sharps
Disposable items
Cleaning equipment
Detergents
Dress code
Chart recording
Biological monitoring
Time
Testing/ Monitoring
Test control
Recording
Wrapping materials
Autoclave tape
Dust covers
Proper towel/ linen folding
Proper labeling
Expiration dates
Packing for steam
Heat sealing
Instrument count sheets
Placing instruments on trays
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.
