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
Wound Care/ Surgical
Wound Care/ Medical
Dressing Changes
Skin Assessment
Suture Staple removal
Cast Care
PICC insertion
Total Joint replacements
Prosthesis Application
Sliding boards
Stroke precautions
Assistive devices
Discharge planning
Standard extremity braces
TPN protocols and site care
Team charting
Stump wrapping
GT/PEG feedings
Oxygen delivery devices
Nebulizer use
Head injury
Trauma-lacerations
Tracheostomy care
Ventilator
MSDS assessments
UR/ Medicare review
Newborn/Neonatal (up to 30 days)
Infant (30 days to 1 year)
Toddler (1 to 3 years)
Pre-school (3 to 5 years)
School Age (5 to 12 years)
Adolescent (12 to 18 years)
Young Adult (18 to 30 years)
Mature Adult (30 to 60 years)
Elderly (60 & up)
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.
