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
Abdominal
Pancreas
Liver
Pelvis
Temporomandibular
Adrenal
Aorta
Thorax
Brain CT Scans Contrast Non-contrast
Chest
Orbit
Pulmonary embolism
Internal Auditory canal
Facial Bone
Sinus
Mastoid Scan
Neck Scans
Thoracic Scans
Cervical Spines
Lumbar/Sacral Spine Scans
Post Myelogram scans
Trauma Spinal scans
Upper extremity scans
Lower extremity scans
Renal CT Renal cyst puncture
Spin-echo images
Surface coils
Biopsy procedures
Gradient Echo imaging
CT guided Thoracic drainage’s, abdominal drainages
Pediatric Head CT Scans
Pediatric thoracic and abdominal CT Scans
Quality improvement studies/participation
General Electric
Hitachi
Kodak Processor
Siemens
Phillips
High speed Advantage
Radiation badge/ PPE
Hewlett Packard
Other (list)
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)
BLS
5
CNRN
ACLS
CCRN
Other:
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.
