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
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School Age Child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)
Acute Care/ Hospital
Managed Care
SNF/ Long Term Care
Home Health
Outpatient
Written Communication Skills
Verbal Communication Skills
Basic Negotiation Skills
Job Related Computer Skills
Ability to Prioritize
Ability to Educate through Different Methods (Cognitive, Affective, and Psychomotor)
Possess Strong Leadership Skills
Possess Clinical Knowledge
Ability to Work Effectively in All Situations
Ability to Critically Think and Problem Solve
Up to Date on Clinical Evidenced Based Practices
Monitoring and Evaluation
Theories and Principles of Adult Learning
Ability to Develop and Implement Relevant Nursing Curriculum
Ability to Identify and Manage Educational Opportunities
Ability to Delegate Appropriately
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.
