_ 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 / IV THERAPY ADMINISTER PO MEDICATIONS 1 2 3 4 5 ADMINISTER TOPICAL MEDICATIONS 1 2 3 4 5 ADMINISTER IM / SQ MEDICATIONS 1 2 3 4 5 ADMINISTER IV MEDICATIONS 1 2 3 4 5 NEEDLE-LESS SYSTEMS 1 2 3 4 5 INFUSION PUMPS 1 2 3 4 5 ESTABLISH PERIPHERAL IVS 1 2 3 4 5 DISCONTINUE PERIPHERAL IVS 1 2 3 4 5 PAIN ASSESSMENT / MANAGEMENT 1 2 3 4 5 DRAW BLOOD FOR LAB STUDIES 1 2 3 4 5 ADMIN BLOOD / BLOOD PRODUCTS 1 2 3 4 5 CENTRAL VENOUS LINES (CVL) 1 2 3 4 5 HICKMAN / BROVIAC CATHETERS 1 2 3 4 5 PORT-A-CATH 1 2 3 4 5 INFUSAID 1 2 3 4 5 INFUSE-A-PORT 1 2 3 4 5 PCA 1 2 3 4 5 Version: 07/03/2012 Page 1 out of 7
MEDICATIONS / IV THERAPY CADD 1 2 3 4 5 CARE OF ONCOLOGICAL PATIENT HEAD, NECK, CHEST 1 2 3 4 5 HEMATOLOGIC SYSTEM 1 2 3 4 5 GASTROINTESTINAL TRACT 1 2 3 4 5 REPRODUCTIVE SYSTEM 1 2 3 4 5 SKIN (MELANOMAS / NONMELANOMAS) 1 2 3 4 5 URINARY TRACT 1 2 3 4 5 EMERGENCIES CARDIAC TAMPONADE 1 2 3 4 5 DISSESMINATED INTRAVASCULAR COAGULATION 1 2 3 4 5 HYPERCALCEMIA 1 2 3 4 5 ORGAN OBSTRUCTION 1 2 3 4 5 SEPSIS 1 2 3 4 5 SPINAL CORD COMPRESSION 1 2 3 4 5 SUPERIOR VENA CAVAE SYNDROME 1 2 3 4 5 TUMOR LYSIS SYNDROME 1 2 3 4 5 FAMILY / PSYCHOSOCIAL NEEDS PATIENT / FAMILY EDUCATION 1 2 3 4 5 ADVANCE DIRECTIVES 1 2 3 4 5 ACUTE PHASE 1 2 3 4 5 CHRONIC PHASE 1 2 3 4 5 TERMINAL PHASE 1 2 3 4 5 BEREAVEMENT PHASE 1 2 3 4 5 AFTER TREATMENT (SURVIVORSHIP) 1 2 3 4 5 CANCER THERAPY - RADIATION THERAPY (RT) ELECTROMAGNETIC (XRAYS, GAMMA RAYS) 1 2 3 4 5 PARTICULATE (ALPHA, BETA) 1 2 3 4 5 EXTERNAL BEAM THERAPY 1 2 3 4 5 KNOWLEDGE OF EARLY EFFECTS OF RT 1 2 3 4 5 Version: 07/03/2012 Page 2 out of 7
CANCER THERAPY - RADIATION THERAPY (RT) KNOWLEDGE OF INTERM. EFFECTS OF RT 1 2 3 4 5 BRACHYTHERAPY (SEALED SOURCES) INTERSTITIAL RADIATION THERAPY 1 2 3 4 5 INTRACAVITARY RADIATION THERAPY 1 2 3 4 5 INTRALUMINAL RADIATION THERAPY 1 2 3 4 5 RADIOPHARMACEUTICAL -UNSEALED SOURCES TRACER DOSE 1 2 3 4 5 THERAPEUTIC DOSE 1 2 3 4 5 SURGICAL INTERVENTION CURATIVE SURGERY 1 2 3 4 5 DIAGNOSTIC SURGERY 1 2 3 4 5 MECHANICAL DEVICE INSERTION 1 2 3 4 5 PALLIATIVE SURGERY 1 2 3 4 5 PROPHYLACTIC SURGERY 1 2 3 4 5 RECONSTRUCTIVE SURGERY 1 2 3 4 5 REHABILITATIVE SURGERY 1 2 3 4 5 BONE MARROW TRANSPLANT - ALLOGENIC 1 2 3 4 5 BONE MARROW TRANSPLANT - SYNGENIC 1 2 3 4 5 ONCOLOGY HEALTH CARE SETTINGS ADULT 1 2 3 4 5 PEDS 1 2 3 4 5 CANCER CENTER 1 2 3 4 5 RADIATION ONCOLOGY 1 2 3 4 5 SURGICAL ONCOLOGY 1 2 3 4 5 BONE MARROW UNIT 1 2 3 4 5 RESEARCH / CLINICAL TRIALS 1 2 3 4 5 SUBACUTE / SKILLED NURSING 1 2 3 4 5 HOME HEALTH CARE 1 2 3 4 5 HOSPICE 1 2 3 4 5 CLINIC - RISK ASSESS / SCREENING / DIAGNOSIS 1 2 3 4 5 Version: 07/03/2012 Page 3 out of 7
ONCOLOGY HEALTH CARE SETTINGS CLINIC - SURGERY / GYN 1 2 3 4 5 CLINIC - MEDICAL / HEMATOLOGY 1 2 3 4 5 CLINIC - IMMUNOLOGY / INFECTIOUS 1 2 3 4 5 ANTINEOPLASTIC AGENTS - ROUTES OF ADMINISTRATION ORAL / SQ / IM 1 2 3 4 5 INTRAVENOUS 1 2 3 4 5 INTRAARTERIAL 1 2 3 4 5 INTRATHECAL / INTRAVENTRICULAR 1 2 3 4 5 INTRAPERITONEAL (TENCKHOFF CATHETER) 1 2 3 4 5 INTRAPLEURAL 1 2 3 4 5 INTRAVESICULAR 1 2 3 4 5 ALKYLATING AGENTS BULSULFAN (MYLERAN) 1 2 3 4 5 CHLORAMBUCIL (LEUKERAN) 1 2 3 4 5 CISPLATIN (PLATINOL) 1 2 3 4 5 CYCLOPHOSPHAMIDE (CYTOXAN) 1 2 3 4 5 MECHLORETHAMINE (MUSTARGEN) 1 2 3 4 5 ANTIMETABOLITES CYTARABINE (ARA-C) 1 2 3 4 5 FLUOROURACIL (5-FU) 1 2 3 4 5 MERCAPTOPURINE (6-MP) 1 2 3 4 5 METHOTREXATE 1 2 3 4 5 LEUCOVORIN RESCUE PROTOCOL 1 2 3 4 5 ANTINEOPLASTIC ANTIBIOTICS BLEOMYCIN 1 2 3 4 5 DACTINOMYCIN (ACTINOMYCIN) 1 2 3 4 5 DAUNORUBICIN (DAUNOXOME) 1 2 3 4 5 DOXORUBICIN (ADRIAMYCIN) 1 2 3 4 5 PLANT ALKALOIDS PACLITAXEL (TAXOL) 1 2 3 4 5 Version: 07/03/2012 Page 4 out of 7
PLANT ALKALOIDS VINBLASTINE (VELBAN) 1 2 3 4 5 VINCRISTINE (ONCOVIN) 1 2 3 4 5 HORMONAL ANTINEOPLASTICS LEUPROLIDE (LUPRON) 1 2 3 4 5 MEGESTROL (MEGACE) 1 2 3 4 5 TAMOXIFEN (NOLVADEX) 1 2 3 4 5 TESTOLACTONE (TESLAC) 1 2 3 4 5 STAFF MINIMIZE RISK OF EXPOSURE DURING PREPARATION 1 2 3 4 5 DURING ADMINISTRATION 1 2 3 4 5 DURING DISPOSAL 1 2 3 4 5 TREATMENT SIDE EFFECTS - RECOGNITION & MANAGEMENT OF ANXIETY / DEPRESSION 1 2 3 4 5 METABOLIC ALTERATIONS 1 2 3 4 5 HYPERSENSITIVITY 1 2 3 4 5 FATIGUE 1 2 3 4 5 HEMATOPOIETIC ANEMIA 1 2 3 4 5 LEUKOPENIA 1 2 3 4 5 THROMBOCYTOPENIA 1 2 3 4 5 GASTROINTESTINAL ANOREXIA / DEHYDRATION 1 2 3 4 5 NAUSEA / VOMITING 1 2 3 4 5 CONSTIPATION / DIARRHEA 1 2 3 4 5 MUSCOSITIS / ULCERATION 1 2 3 4 5 HEPATIC TOXICITY 1 2 3 4 5 INTEGUMENTARY ALOPECIA 1 2 3 4 5 LOPECIA 1 2 3 4 5 LOPECIA 1 2 3 4 5 Version: 07/03/2012 Page 5 out of 7
GENITOURINARY CYSTITIS 1 2 3 4 5 RENAL TOXICITY 1 2 3 4 5 CARDIOVASCULAR CARDIAC TOXICITY 1 2 3 4 5 PHLEBITIS 1 2 3 4 5 EXTRAVASATION 1 2 3 4 5 NEUROLOGIC NEUROTOXICITY 1 2 3 4 5 OTOTOXICITY 1 2 3 4 5 METABOLIC ENCEPHALOPATHY 1 2 3 4 5 PERIPHERAL NEUROPATHY 1 2 3 4 5 PULMONARY FIBROSIS 1 2 3 4 5 PNEUMONITIS 1 2 3 4 5 EDEMA 1 2 3 4 5 REPRODUCTIVE INFERTILITY 1 2 3 4 5 CHANGES IN LIBIDO 1 2 3 4 5 ERECTILE DYSFUNCTION 1 2 3 4 5 NUTRITION ASSESS NUTRITIONAL STATUS 1 2 3 4 5 ASSESS / MANAGE NUTRITIONAL IMPAIRME 1 2 3 4 5 INTERPRETATION OF LAB VALUES 1 2 3 4 5 ORAL FEEDINGS 1 2 3 4 5 ENTERAL TUBE FEEDING 1 2 3 4 5 PERIPHERAL PARENTERAL NUTRITION (PPN) 1 2 3 4 5 CENTRAL TPN 1 2 3 4 5 CLASSIFICATION OF NEOPLASMS STAGING - TNM SYSTEM 1 2 3 4 5 Version: 07/03/2012 Page 6 out of 7
CLASSIFICATION OF NEOPLASMS TISSUE OF ORIGIN 1 2 3 4 5 BIOLOGIC BEHAVIOR 1 2 3 4 5 DEGREE OF CELL DIFFERENTIATION 1 2 3 4 5 ANATOMIC SITE 1 2 3 4 5 AGE APPROPRIATE CARE NEWBORN (BIRTH-30 DAYS) 1 2 3 4 5 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 7 out of 7