_ XXX-XX- Print Name Last 4 of SS # Date Completed Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 - No (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited (requires assistance or training) - performed within the last 24 months 4 - d (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 months MEDICATIONS ADMINISTER PO MEDICATIONS 1 2 3 4 5 ADMINISTER RECTAL MEDICATIONS 1 2 3 4 5 ADMINISTER NG MEDICATIONS 1 2 3 4 5 ADMINISTER IM & SQ MEDS 1 2 3 4 5 IV PUSH MEDS 1 2 3 4 5 ADMINISTER EYE / EAR MEDS 1 2 3 4 5 METERED DOSE INHALER 1 2 3 4 5 KNOWLEDGE ROUTINE PEDS MEDS 1 2 3 4 5 CALCULATION OF PEDIATRIC DOSES 1 2 3 4 5 KNOWLEDGE OF EMERGENCY MEDS 1 2 3 4 5 PAIN ASSESSMENT / MANAGEMENT 1 2 3 4 5 ADMIN. HYPERALIMENTATION / PTN 1 2 3 4 5 KNOWLEDGE OF IMMUNIZATION SCHED. 1 2 3 4 5 HICKMAN / BROVIAC CATHETERS 1 2 3 4 5 EPIDURAL ANESTHESIA / ANALGESIA 1 2 3 4 5 CONSCIOUS SEDATION 1 2 3 4 5 Version: 07/03/2012 Page 1 out of 10
NARCOTIC ANALGESIA 1 2 3 4 5 PCA PUMP 1 2 3 4 5 ACUTE TUMOR LYSIS SYNDROME 1 2 3 4 5 HEMATOLOGY/ONCOLOGY ASSESS NUTRITIONAL STATUS 1 2 3 4 5 INTERPRETATION OF LAB RESULTS 1 2 3 4 5 REVERSE ISOLATION 1 2 3 4 5 ANEMIA 1 2 3 4 5 LEUKEMIA 1 2 3 4 5 HIV / AIDS 1 2 3 4 5 HEMOPHILIA 1 2 3 4 5 DEPRESSED IMMUNE SYSTEM 1 2 3 4 5 BONE MARROW TRANSPLANT 1 2 3 4 5 SICKLE CELL DISEASE 1 2 3 4 5 PRE / POST ONCOLOGIC SURGERY 1 2 3 4 5 SPLEEN TRAUMA / SPLENECTOMY 1 2 3 4 5 CHEMOTHERAPY 1 2 3 4 5 DIC 1 2 3 4 5 INFUSION THERAPY - PERIPHERAL IV INSERTION - BUTTERFLY 1 2 3 4 5 - HEPARIN / SALINE LOCK 1 2 3 4 5 - ANGIOCATH 1 2 3 4 5 NEEDLE-LESS SYSTEMS 1 2 3 4 5 MIX IV INFUSION W/ ADDITIVES 1 2 3 4 5 INFUSION PUMPS 1 2 3 4 5 SYRINGE PUMPS 1 2 3 4 5 IV DRESSING & TUBING CHANGES 1 2 3 4 5 IV SITE & PATENCY ASSESSMENT 1 2 3 4 5 DISCONTINUE PERIPHERAL IVS 1 2 3 4 5 Version: 07/03/2012 Page 2 out of 10
INFUSION THERAPY - PERIPHERAL IV INSERTION CVLS DRESSING CHANGE 1 2 3 4 5 FLUID RESUSCITATION 1 2 3 4 5 GROSHONG 1 2 3 4 5 QUINTON 1 2 3 4 5 IMPLANTABLE VENOUS PORT (PORTACATH) 1 2 3 4 5 PICC LINE 1 2 3 4 5 VASCULAR DRAW VENOUS BLOOD (PERIPHERAL) 1 2 3 4 5 INTERPRETATION OF LAB RESULTS 1 2 3 4 5 DRAW BLOOD FROM CENTRAL LINE 1 2 3 4 5 ADMIN BLOOD / BLOOD PRODUCTS - PACKED RBCS 1 2 3 4 5 - CRYOPRECIPITATE 1 2 3 4 5 - PLASMA / ALBUMIN 1 2 3 4 5 - WHOLE BLOOD 1 2 3 4 5 ASSESS FOR EDEMA / FLUID OVERLOAD 1 2 3 4 5 PERIPHERAL PULSES 1 2 3 4 5 ULTRASONIC DOPPLER 1 2 3 4 5 INFECTIOUS DISEASES ASSESS / INTERPRET LAB STUDIES 1 2 3 4 5 FEVER MANAGEMENT 1 2 3 4 5 COMMON CHILDHOOD DISEASES 1 2 3 4 5 CYTOMEGALO VIRUS (CMV) 1 2 3 4 5 KAWASAKI DISEASE 1 2 3 4 5 LYME DISEASE 1 2 3 4 5 CARDIAC ASSESS CARDIAC & PERFUSION STATUS 1 2 3 4 5 ASSESS HEART SOUNDS 1 2 3 4 5 Version: 07/03/2012 Page 3 out of 10
CARDIAC ASSESS BP (NONINVASIVE) 1 2 3 4 5 USE OF CARDIAC MONITORS 1 2 3 4 5 INTERPRETATION OF ARRHYTHMIAS 1 2 3 4 5 ASSIST WITH CODE / CPR 1 2 3 4 5 DEFIBRILLATION / CARDIOVERSION 1 2 3 4 5 KNOWLEDGE OF EMERGENCY MEDS 1 2 3 4 5 KNOWLEDGE OF CARDIAC MEDS 1 2 3 4 5 ASSIST WITH INSERTION & MAINTAIN - ARTERIAL LINES 1 2 3 4 5 - CENTRAL VENOUS CATHETER 1 2 3 4 5 - PA CATHETER 1 2 3 4 5 PRE / POST CARDIAC CATH 1 2 3 4 5 PRE / POST CARDIAC SURGERY 1 2 3 4 5 HYPOVOLEMIC SHOCK 1 2 3 4 5 CARDIOGENIC SHOCK 1 2 3 4 5 CONGESTIVE HEART FAILURE 1 2 3 4 5 CONGENITAL HEART DEFECTS / DISEASE 1 2 3 4 5 PATENT DUCTUS ARTERIOSUS (PDA) 1 2 3 4 5 ATRIOVENTRICULAR SEPTAL DEFECTS 1 2 3 4 5 COARCTATION OF THE AORTA 1 2 3 4 5 TRANSPOSITION OF THE GREAT ARTERIES 1 2 3 4 5 PULMONARY ATRESIA 1 2 3 4 5 HEART TRANSPLANT 1 2 3 4 5 NEUROLOGY NEUROLOGICAL ASSESSMENT 1 2 3 4 5 GLASCOW COMA SCALE (PEDS) 1 2 3 4 5 ASSIST WITH LUMBAR PUNCTURE 1 2 3 4 5 INTRACRANIAL PRESSURE MONITORING 1 2 3 4 5 SEIZURE PRECAUTIONS 1 2 3 4 5 Version: 07/03/2012 Page 4 out of 10
NEUROLOGY KNOWLEDGE / USE OF ANTICONVULSANTS 1 2 3 4 5 OPEN / CLOSED HEAD INJURY 1 2 3 4 5 INTERNAL / EXTERNAL SHUNTS 1 2 3 4 5 ACUTE SPINAL CORD INJURY 1 2 3 4 5 MENINGITIS / ENCEPHALITIS 1 2 3 4 5 OVERDOSE / INGESTION 1 2 3 4 5 NEAR DROWNING 1 2 3 4 5 SPINA BIFIDA 1 2 3 4 5 REYE'S SYNDROME 1 2 3 4 5 BATTERED CHILD SYNDROME 1 2 3 4 5 NEUROMUSCULAR DISEASE 1 2 3 4 5 BRAIN DEATH / ORGAN PROCUREMENT 1 2 3 4 5 STATUS EPILEPTICUS 1 2 3 4 5 ORTHOPEDIC SPECIALIZED ORTHOPEDIC BED 1 2 3 4 5 CAST CARE / SPICA CAST 1 2 3 4 5 MULTIPLE FRACTURES 1 2 3 4 5 AMPUTATION 1 2 3 4 5 SKELETAL TRACTION 1 2 3 4 5 SKIN TRACTION 1 2 3 4 5 POST HARRINGTON ROD INSERTION 1 2 3 4 5 OSTEOMYELITIS 1 2 3 4 5 RESPIRATORY ASSESS RESPIRATORY STATUS 1 2 3 4 5 ASSESS BREATH SOUNDS 1 2 3 4 5 ORAL AIRWAY & SUCTIONING 1 2 3 4 5 USE OF BULB SYRINGE 1 2 3 4 5 OBTAIN ABGS - ARTPUNCTURE / HEELSTICK 1 2 3 4 5 Version: 07/03/2012 Page 5 out of 10
RESPIRATORY OBTAIN ABGS - ARTERIAL LINE 1 2 3 4 5 INTERPRET ABGS 1 2 3 4 5 ASSIST W/ INTUBATION (ETT) 1 2 3 4 5 ETT MAINTENANCE AND SUCTIONING 1 2 3 4 5 END TIDAL CO2 MONITOR 1 2 3 4 5 ETT EXTUBATION 1 2 3 4 5 VENTILATE WITH AMBU-BAG 1 2 3 4 5 APNEA MONITOR 1 2 3 4 5 NEBULIZER 1 2 3 4 5 OXYGEN DELIVERY - ISOLETTE 1 2 3 4 5 - HOOD / TENT 1 2 3 4 5 - NASAL CANNULA & FACE MASK 1 2 3 4 5 PRESSURE VENTILATOR 1 2 3 4 5 VOLUME VENTILATOR 1 2 3 4 5 CPAP / PEEP / IMV 1 2 3 4 5 VENTILATOR WEANING 1 2 3 4 5 ECMO 1 2 3 4 5 CHEST PHYSIOTHERAPY 1 2 3 4 5 CHEST TUBES-ASSIST INSERTION/REMOVAL 1 2 3 4 5 ASTHMA / STATUS ASTHMATICUS 1 2 3 4 5 EPIGLOTTITIS & TONSILLITIS 1 2 3 4 5 BRONCHIOLITIS (RSV) 1 2 3 4 5 SEVERE RESPIRATORY DISTRESS 1 2 3 4 5 PNEUMONIA 1 2 3 4 5 TRACHEOSTOMY 1 2 3 4 5 BRONCHOPULMONARY DYSPLASIA(BPD) 1 2 3 4 5 CYSTIC FIBROSIS 1 2 3 4 5 TRACHEO-ESOPHAGEAL FISTULA 1 2 3 4 5 Version: 07/03/2012 Page 6 out of 10
HEMO / PNEUMO THORAX 1 2 3 4 5 FOREIGN BODY ASPIRATION 1 2 3 4 5 LUNG TRANSPLANT 1 2 3 4 5 WOUND MANAGEMENT ASSESS SKIN FOR BREAKDOWNS 1 2 3 4 5 SURGICAL WOUND CARE 1 2 3 4 5 TRAUMATIC WOUND CARE 1 2 3 4 5 WOUND DRAINS (JP / HEMOVAC) 1 2 3 4 5 USE OF AIR BEDS 1 2 3 4 5 PRESSURE SORES / DECUBITUS ULCERS 1 2 3 4 5 BURNS (1ST & 2ND DEGREE) 1 2 3 4 5 BURNS (3RD DEGREE) 1 2 3 4 5 ENDOCRINE ASSESS / INTERPRET LAB STUDIES 1 2 3 4 5 DIABETIC TEACHING 1 2 3 4 5 ADRENAL DISORDERS 1 2 3 4 5 CUSHING'S SYNDROME 1 2 3 4 5 JUVENILE DIABETES 1 2 3 4 5 INSULIN PUMP 1 2 3 4 5 PITUITARY DISORDERS 1 2 3 4 5 THYROID DISORDERS 1 2 3 4 5 GASTROINTESTINAL ASSESS BOWEL SOUNDS 1 2 3 4 5 INSERTION / MONITORING NG TUBE 1 2 3 4 5 INSERTION / MONITORING OG TUBE 1 2 3 4 5 ASSIST W/ BOTTLE & BREAST FEEDING 1 2 3 4 5 TUBE FEEDINGS VIA FLEXIBLE TUBES 1 2 3 4 5 GASTROSTOMY TUBE FEEDING 1 2 3 4 5 Version: 07/03/2012 Page 7 out of 10
GASTROENTERITIS / SEVERE DEHYDRATION 1 2 3 4 5 GASTROSCHISIS 1 2 3 4 5 PRE / POST ABDOMINAL SURGERY 1 2 3 4 5 GE REFLUX 1 2 3 4 5 GI BLEED 1 2 3 4 5 COLOSTOMY / ILEOSTOMY 1 2 3 4 5 NECROTIZING ENTEROCOLITIS (NEC) 1 2 3 4 5 PANCREATITIS 1 2 3 4 5 HEPATITIS 1 2 3 4 5 HEPATIC FAILURE 1 2 3 4 5 ABDOMINAL WOUNDS & DRAINS 1 2 3 4 5 FAILURE TO THRIVE 1 2 3 4 5 CLEFT LIP / PALATE 1 2 3 4 5 CRANIOFACIAL RECONSTRUCTION 1 2 3 4 5 LIVER TRANSPLANT 1 2 3 4 5 GENERAL NURSING ADMIT & ORIENT PATIENTS 1 2 3 4 5 NORMAL GROWTH AND DEVELOPMENT 1 2 3 4 5 RECOGNIZE SIGNS OF ABUSE / NEGLECT 1 2 3 4 5 WEIGH PATIENT 1 2 3 4 5 DISCHARGE PATIENTS 1 2 3 4 5 SUPERVISE UNLICENSED PERSONNEL 1 2 3 4 5 PULSE OXIMETRY 1 2 3 4 5 BLOOD GLUCOSE MONITORING 1 2 3 4 5 POSITIONING / TRANSFERRING 1 2 3 4 5 RESTRAINTS 1 2 3 4 5 ISOLATION TECHNIQUES 1 2 3 4 5 UNIVERSAL PRECAUTIONS / PEP 1 2 3 4 5 Version: 07/03/2012 Page 8 out of 10
RENAL/GENITOURINARY STRAIGHT / FOLEY CATH FEMALE 1 2 3 4 5 STRAIGHT / FOLEY CATH MALE 1 2 3 4 5 COLLECT URINE SPECIMEN(DIAPER / BAG) 1 2 3 4 5 ASSIST WITH SUPRA-PUBIC TAP 1 2 3 4 5 INTERPRET ELECTROLYTES, BUN, CREAT 1 2 3 4 5 INTERPRET URINALYSIS 1 2 3 4 5 TEST & INTERPRET URINE / LABSTIX 1 2 3 4 5 TEST & INTERPRET URINE SP. GR. 1 2 3 4 5 NEPHROSTOMY TUBE 1 2 3 4 5 GENITOURINARY TRAUMA 1 2 3 4 5 ACUTE RENAL FAILURE 1 2 3 4 5 NEPHRITIS 1 2 3 4 5 SHUNTS & FISTULAS 1 2 3 4 5 RENAL TRANSPLANT 1 2 3 4 5 HEMODIALYSIS 1 2 3 4 5 PERITONEAL DIALYSIS 1 2 3 4 5 NEPHROTIC SYNDROME 1 2 3 4 5 POST URINARY DIVERSION 1 2 3 4 5 HEMOLYTIC UREMIC SYNDROME 1 2 3 4 5 DIABETES INSIPIDUS (DI) 1 2 3 4 5 SYNDROME INAPPROPRIATE ADH (SIADH) 1 2 3 4 5 PRE-OPERATIVE CARE / PREPARATION 1 2 3 4 5 GENERAL POST-ANESTHESIA CARE 1 2 3 4 5 MULTIPLE TRAUMA PATIENT 1 2 3 4 5 PENETRATING TRAUMA PATIENT 1 2 3 4 5 INGESTIONS 1 2 3 4 5 DEPRESSION 1 2 3 4 5 ANOREXIA / BULIMIA 1 2 3 4 5 SUICIDAL THREATS / ACTIONS 1 2 3 4 5 Version: 07/03/2012 Page 9 out of 10
ENT SURGERY / PROCEDURES 1 2 3 4 5 OPHTHALMIC SURGERY 1 2 3 4 5 PLASTIC SURGERY 1 2 3 4 5 POSTMORTEM CARE 1 2 3 4 5 AGE APPROPRIATE CARE INFANT (30 DAYS - 1 YEAR) 1 2 3 4 5 TODDLER (1-3 YEARS) 1 2 3 4 5 PRESCHOOLER (3-5 YEARS) 1 2 3 4 5 SCHOOL AGE (5-12 YEARS) 1 2 3 4 5 ADOLESCENTS (12-18 YEARS) 1 2 3 4 5 YOUNG ADULTS (18-39 YEARS) 1 2 3 4 5 MIDDLE ADULTS (39-64 YEARS) 1 2 3 4 5 OLDER ADULTS (64+ YEARS) 1 2 3 4 5 The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services, Corp to share the above skills checklist with its facility clients. Signature Date Completed Fax: 718-225-9421 Version: 07/03/2012 Page 10 out of 10