_ 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 NEUROLOGY ICP MONITORING 1 2 3 4 5 NEUROLOGICAL ASSESSMENT 1 2 3 4 5 SPINAL DISORDERS 1 2 3 4 5 EXTERNAL VP SHUNTS 1 2 3 4 5 SEIZURES 1 2 3 4 5 DRUG/ALCOHOL WITHDRAWAL 1 2 3 4 5 MENINGITIS 1 2 3 4 5 NEUROLOGICAL DEVELOPMENT 1 2 3 4 5 CARDIOVASCULAR HYOPOLEMIC SHOCK 1 2 3 4 5 PULSE/PERFUSION ASSESSMENT 1 2 3 4 5 CONGENITAL HEART DISEASE 1 2 3 4 5 HEMODYNAMIC MONITORING 1 2 3 4 5 HEMODYNAMIC INSTABILITY 1 2 3 4 5 CARDIOVERSION 1 2 3 4 5 CARDIAC ARREST 1 2 3 4 5 POST CARDIAC SURGERY 1 2 3 4 5 Version: 07/03/2012 Page 1 out of 6
CARDIOVASCULAR HEART SOUND AUSCULTATION 1 2 3 4 5 DINAMAP/BP MONITORING 1 2 3 4 5 CV ASSESMENT 1 2 3 4 5 NRP PROTOCOLS & MEDICATIONS 1 2 3 4 5 USE OF S.T.A.B.L.E PROGRAM & PROTOCOLS 1 2 3 4 5 EKG INTERPRETATION & TREATMENT 1 2 3 4 5 CARE OF PATIENT WITH CHF 1 2 3 4 5 RESPIRATORY TRACHEOSTOMY 1 2 3 4 5 DIAPHRAGMATIC HERNIA 1 2 3 4 5 PERIPHERAL ARTERIAL LINES 1 2 3 4 5 INTUBATION ASSISTANCE 1 2 3 4 5 ABG / CAPILLARY 1 2 3 4 5 ABG / UAC 1 2 3 4 5 ABG INTERPRETATION 1 2 3 4 5 ETT STABILIZATION 1 2 3 4 5 BAG AND MASK/SELF INFLATING 1 2 3 4 5 PULSE OXIMETER 1 2 3 4 5 ORAL/NASAL SUCTIONING 1 2 3 4 5 TRANSCUTANEOUS MONITORING 1 2 3 4 5 MECONIUM ASPIRATIONS/MAS 1 2 3 4 5 ETT CATHETER SUCTIONING 1 2 3 4 5 CHEST AUSCULTATION / EXAM 1 2 3 4 5 BAG AND MASK/ANESTHESIA 1 2 3 4 5 ARTIFICIAL SURFACTANT USE 1 2 3 4 5 OXYHOOD 1 2 3 4 5 CPAP/PEEP 1 2 3 4 5 NITRIC OXIDE THERAPY 1 2 3 4 5 PNEUMOTHORAX 1 2 3 4 5 OSCILLATOR 1 2 3 4 5 Version: 07/03/2012 Page 2 out of 6
RESPIRATORY IMV 1 2 3 4 5 NASAL CANNULA 1 2 3 4 5 RDS 1 2 3 4 5 HIGH FREQUENCY JET VENT (HFJV) 1 2 3 4 5 PARTIAL LIQUID VENTILATION 1 2 3 4 5 CARE OF PATIENT WITH APNEA 1 2 3 4 5 IV THERAPY & PHLEBOTOMY HICKMAN 1 2 3 4 5 UVC 1 2 3 4 5 PICC 1 2 3 4 5 BROVIAC 1 2 3 4 5 IV PUMPS 1 2 3 4 5 PERCUTANEOUS ARTERIAL LINE 1 2 3 4 5 HYPERALIMENTATION 1 2 3 4 5 BLOOD /BLOOD BYPRODUCTS 1 2 3 4 5 CENTRAL LINE BLOOD SAMPLES 1 2 3 4 5 VENIPUNCTURE 1 2 3 4 5 IV START UP 1 2 3 4 5 PIV 1 2 3 4 5 HYPERALIMENTATION 1 2 3 4 5 GASTROINTESTINAL NECROTIZING ENTEROCOLITIS 1 2 3 4 5 NASOGASTRIC TUBES 1 2 3 4 5 BOWEL SOUNDS 1 2 3 4 5 POST ABDOMINAL SURGERY 1 2 3 4 5 FEEDING INTOLERANCE 1 2 3 4 5 OCCULT BLOOD TESTING 1 2 3 4 5 ABDOMINAL GIRTH 1 2 3 4 5 TRACHEOESOPHOGEAL FISTULA 1 2 3 4 5 REFLUX PRECAUTIONS 1 2 3 4 5 Version: 07/03/2012 Page 3 out of 6
GASTROINTESTINAL ILEOSTOMY CARE 1 2 3 4 5 INGUINAL HERNIA 1 2 3 4 5 SWALLOW/SUCK PATTERN 1 2 3 4 5 NGT/NJT/OGT PLACEMENT 1 2 3 4 5 CLEFT PALATE/LIP 1 2 3 4 5 BREASTFEEDING ASSISTANCE 1 2 3 4 5 OMPHALOCELE 1 2 3 4 5 COLOSTOMY CARE 1 2 3 4 5 GASTROSTOMY TUBES 1 2 3 4 5 GASTROSCHISIS 1 2 3 4 5 GAVAGE FEEDINGS 1 2 3 4 5 BOTTLE FEEDINGS 1 2 3 4 5 INFECTIOUS DISEASES ISOLATIONS PROCEDURES 1 2 3 4 5 CULTURE SPECIMENS 1 2 3 4 5 LUMBAR PUNCTURE ASSISTANCE 1 2 3 4 5 HBSAG +/ MOTHER 1 2 3 4 5 CBC/DIFFERENTIALS 1 2 3 4 5 RESPIAM / SYNERGIS PROPHYLAXIS 1 2 3 4 5 UNIVERSAL PRECAUTIONS 1 2 3 4 5 MATERNAL SERUM LAB VALUES 1 2 3 4 5 HIV +/MOTHER 1 2 3 4 5 CULTURE SPECIMENS 1 2 3 4 5 NEONATAL SEPSIS 1 2 3 4 5 IMMUNIZATIONS 1 2 3 4 5 ANTI-INFECTIVES 1 2 3 4 5 GENITOURINARY & RENAL EXTERNAL ORGAN DISORDER 1 2 3 4 5 CIRCUMCISION ASSISTANCE 1 2 3 4 5 PERITONEAL DIALYSIS 1 2 3 4 5 Version: 07/03/2012 Page 4 out of 6
GENITOURINARY & RENAL GU TRACT MALFORMATIONS 1 2 3 4 5 ACUTE RENAL FAILURE 1 2 3 4 5 POST CIRCUMCISION CARE 1 2 3 4 5 URINARY CATHETER INSERTION & MANAGEMENT 1 2 3 4 5 PHARMACOLOGY PROSTAGLANDIN 1 2 3 4 5 INSULIN DRIPS 1 2 3 4 5 NAHCO3 1 2 3 4 5 STEROIDS 1 2 3 4 5 AMINOPHYLLINE 1 2 3 4 5 NAHCO3 1 2 3 4 5 ENDOCRINE IDM CARE 1 2 3 4 5 ELECTROLYTE/FLUID IMBALANCE 1 2 3 4 5 NORMAL SERUM LABS 1 2 3 4 5 GLUCOMETER/ACCUCHECK 1 2 3 4 5 MISCELLANEOUS PAIN MANAGEMENT/POST-OP 1 2 3 4 5 WOUND HEALING 1 2 3 4 5 PAIN LEVEL ASSESSMENT 1 2 3 4 5 SEDATION WITH A NEONATE 1 2 3 4 5 SKIN COLOR CHANGE/INTEGRITY 1 2 3 4 5 LOW BIRTH WEIGHT NURSING CARE 1 2 3 4 5 ISOLETTE W/ HUMIDITY 1 2 3 4 5 APGAR SCORING 1 2 3 4 5 HIGH RISK DELIVERIES 1 2 3 4 5 PHOTOTHERAPY CARE 1 2 3 4 5 DUBOWITZ GESTATIONAL AGE 1 2 3 4 5 BALLARD GESTATIONAL AGE 1 2 3 4 5 RADIANT WARMER 1 2 3 4 5 Version: 07/03/2012 Page 5 out of 6
MISCELLANEOUS OPTHAMOLOGY SCREENING 1 2 3 4 5 HEARING SCREENING 1 2 3 4 5 POST MORTEM 1 2 3 4 5 BEREAVEMENT 1 2 3 4 5 EYE EXAM 1 2 3 4 5 CARE OF INFANT UNDER PHOTOTHERAPY 1 2 3 4 5 EXPERIENCE IN LEVEL I NURSERY 1 2 3 4 5 EXPERIENCE IN LEVEL II NURSERY 1 2 3 4 5 AGE APPROPRIATE CARE NEONATAL (LESS THEN 23 WEEKS) 1 2 3 4 5 NEONATAL (24-28 WEEKS) 1 2 3 4 5 NEONATAL (29-32 WEEKS) 1 2 3 4 5 NEONATAL (33 WEEKS OR GREATER) 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 6 out of 6