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
Use of contrast agents
IV insertion
IV maintenance
Setup errors
Technical artifact
M-Mode
Color flow
Real time
Stress echo
Pediatric echocardiogram
Adult echocardiogram
Doppler
Dobutamine stress echocardiogram
TEE (transesophageal esopography)
Duplex
Arterial peripheral upper extremity
Arterial peripheral lower extremity
Arterial peripheral stress/ pressure testing
Carotid artery
Vertebral artery
Subclavian artery
Venous peripheral upper extremity
Venous peripheral lower extremity
Quality control of equipment
Recognition of malfunctions
Transducer selection
Image annotation
Patient variables
Criteria for diagnostic quality
Universal precautions
Disinfection and cleaning
Flow Studies
Photoplethysmography
Strain gauge and Pneumoplethysmography
Newborn birth-30 days
Infant 30 days-1 year
Toddler 1-3 years*
Preschooler 3-5 years
School Age 5-12 years
Adolescents 12-18 years
Young Adults 18-39 years
Middle Adults 39-64 years
Older Adults 64+ 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.
