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My responses in this checklist represent a true reflection of my experience and comfort level.

Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.
 
 
 
   
 
 Signature                  :
       
 
 Date                  :
       
          Phone                  :
     
   My Recruiting Professional at Health Source Group is:
     
          Level of Comfort/Experience

          N/A=Non-applicable

          1=Inexperienced in this area

          
2=Limited comfort/experience in this area

          
3=Comfortable/experienced in this area

          
4= comfortable/highly experienced in this area

 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

CARDIOVASCULAR

Ausculation (rate, rhythm, volume)

N/A  

1

2

3

4

Blood pressure/non-invasive

N/A  

1

2

3

4

Heart sounds/murmurs

N/A  

1

2

3

4

Interpret lab results:

N/A  

1

2

3

4

Arterial blood gases

N/A  

1

2

3

4

Hemoglobin & hematocrit

N/A  

1

2

3

4

Basic EKG interpretation

N/A  

1

2

3

4

Bacterial endocarditis

N/A  

1

2

3

4

Cardiac arrest

N/A  

1

2

3

4

Cardiomyopathy

N/A  

1

2

3

4

Congenital heart defects/disease

N/A  

1

2

3

4

Congestive heart failure

N/A  

1

2

3

4

Myocarditis

N/A  

1

2

3

4

Pericarditis

N/A  

1

2

3

4

Post cardiac cath

N/A  

1

2

3

4

Post cardiac surgery

N/A  

1

2

3

4

Rheumatic fever

N/A  

1

2

3

4

Shock

N/A  

1

2

3

4

Digoxin (Lanoxin) use

N/A  

1

2

3

4

 

PULMONARY

Breath sounds

N/A  

1

2

3

4

Rate and work of breathing

N/A  

1

2

3

4

Bulb syringe use

N/A  

1

2

3

4

Nasal airway/suctioning

N/A  

1

2

3

4

Oral airway/suctioning

N/A  

1

2

3

4

Tracheostomy/suctioning

N/A  

1

2

3

4

Apnea monitor use

N/A  

1

2

3

4

Chest physiotherapy

N/A  

1

2

3

4

Chest tube care

N/A  

1

2

3

4

End tidal CO2

N/A  

1

2

3

4

Face mask

N/A  

1

2

3

4

Hood

N/A  

1

2

3

4

Isolette

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Tent

N/A  

1

2

3

4

Trach collar

N/A  

1

2

3

4

Water seal drainage system

N/A  

1

2

3

4

Asthma

N/A  

1

2

3

4

Bronchiolitis (RSV)

N/A  

1

2

3

4

Bronchopulmonary dysplasia (BPD)

N/A  

1

2

3

4

Croup

N/A  

1

2

3

4

Cystic fibrosis

N/A  

1

2

3

4

Epiglottitis

N/A  

1

2

3

4

Pertussis

N/A  

1

2

3

4

Pneumonia

N/A  

1

2

3

4

Tonsillitis

N/A  

1

2

3

4

Tuberculosis (TB)

N/A  

1

2

3

4

Aminophylline (Theophylline) use

N/A  

1

2

3

4

 

NEUROLOGICAL/ORTHO

Assess level of consciousness

N/A  

1

2

3

4

Assist with lumbar puncture

N/A  

1

2

3

4

ICP monitoring

N/A  

1

2

3

4

Cast care

N/A  

1

2

3

4

Battered child syndrome

N/A  

1

2

3

4

Closed head trauma

N/A  

1

2

3

4

Encephalitis

N/A  

1

2

3

4

Febrile seizures

N/A  

1

2

3

4

Meningitis

N/A  

1

2

3

4

Multiple sclerosis

N/A  

1

2

3

4

Near drowning

N/A  

1

2

3

4

Neuromuscular disease

N/A  

1

2

3

4

Clubfoot

N/A  

1

2

3

4

Multiple trauma

N/A  

1

2

3

4

Pinned fractures

N/A  

1

2

3

4

Traction

N/A  

1

2

3

4

Osteogenic sarcoma

N/A  

1

2

3

4

Osteomyelitis

N/A  

1

2

3

4

Corticosteroids

N/A  

1

2

3

4

Dilantin (Phenytoin)

N/A  

1

2

3

4

Phenobarbital

N/A  

1

2

3

4

Valium (Diazepam)

N/A  

1

2

3

4

 

GASTROINTESTINAL

Abdominal assessment

N/A  

1

2

3

4

Nutritional assessment

N/A  

1

2

3

4

Interpretation of serum electrolyte lab results

N/A  

1

2

3

4

Gavage feedings

N/A  

1

2

3

4

Central hyperalimentation

N/A  

1

2

3

4

Peripheral hyperalimentation

N/A  

1

2

3

4

Jejunal feeding

N/A  

1

2

3

4

Gastrostomy/button

N/A  

1

2

3

4

I-tubes

N/A  

1

2

3

4

NG and sump tubes to suction

N/A  

1

2

3

4

Penrose drains

N/A  

1

2

3

4

Placement of naso/orogastric tube

N/A  

1

2

3

4

Anal fistula

N/A  

1

2

3

4

Cleft lip/palate

N/A  

1

2

3

4

Colostomy

N/A  

1

2

3

4

Diaphragmatic hernia

N/A  

1

2

3

4

Failure to thrive (FTT)

N/A  

1

2

3

4

Gastroenteritis/dehydration

N/A  

1

2

3

4

GE reflux

N/A  

1

2

3

4

Ileostomy

N/A  

1

2

3

4

Intestinal parasites

N/A  

1

2

3

4

Necrotizing enterocolitis (NEC)

N/A  

1

2

3

4

Pyloric stenosis

N/A  

1

2

3

4

Surgical abdomen

N/A  

1

2

3

4

Ulcerative colitis

N/A  

1

2

3

4

 

RENAL/GENITOURINARY

Assess fluid balance

N/A  

1

2

3

4

Interpret BUN and creatinine lab results

N/A  

1

2

3

4

Interpret urinalysis

N/A  

1

2

3

4

Assist with suprapubic tap

N/A  

1

2

3

4

Collect urine specimen

N/A  

1

2

3

4

Foley catheter care

N/A  

1

2

3

4

Foley catheter insertion

N/A  

1

2

3

4

Straight cath

N/A  

1

2

3

4

Circumcision

N/A  

1

2

3

4

Glomerulanephritis

N/A  

1

2

3

4

Hemodialysis

N/A  

1

2

3

4

Hemolytic uremic syndrome(HUS)

N/A  

1

2

3

4

Hypospadias

N/A  

1

2

3

4

Infantile polycystic disease

N/A  

1

2

3

4

Kidney transplant

N/A  

1

2

3

4

Nephrotic syndrome

N/A  

1

2

3

4

Peritoneal dialysis

N/A  

1

2

3

4

Renal failure

N/A  

1

2

3

4

Urinary tract infection (UTI)

N/A  

1

2

3

4

Wilm’s tumor

N/A  

1

2

3

4

 

ENDOCRINE/METABOLIC

Blood glucose testing

N/A  

1

2

3

4

Insulin administration

N/A  

1

2

3

4

Interpret blood glucose results

N/A  

1

2

3

4

Interpret thyroid studies

N/A  

1

2

3

4

Adrenal disorders

N/A  

1

2

3

4

Cushing’s syndrome

N/A  

1

2

3

4

Juvenile diabetes

N/A  

1

2

3

4

Pituitary disorders

N/A  

1

2

3

4

Thyroid malfunction

N/A  

1

2

3

4

 

HEMATOLOGY/ONCOLOGY

Assess nutritional status

N/A  

1

2

3

4

Interpret blood chemistry lab results

N/A  

1

2

3

4

Interpret blood counts

N/A  

1

2

3

4

Reverse isolation

N/A  

1

2

3

4

Anemia

N/A  

1

2

3

4

Bone marrow transplant

N/A  

1

2

3

4

Depressed immune system

N/A  

1

2

3

4

Disseminated intravascular coagulation (DIC)

N/A  

1

2

3

4

Hemophilia

N/A  

1

2

3

4

Hodgkin’s disease

N/A  

1

2

3

4

Infectious mononucleosis

N/A  

1

2

3

4

Leukemia

N/A  

1

2

3

4

Malignant tumors

N/A  

1

2

3

4

Sickle cell anemia

N/A  

1

2

3

4

Spleen trauma/splenectomy

N/A  

1

2

3

4

Prednisone use

N/A  

1

2

3

4

Chemo certification

N/A  

1

2

3

4

 

IV THERAPY

Administration of blood and blood products (Precautions, recognizing transfusion reactions and taking appropriate actions)

N/A  

1

2

3

4

Start peripheral IV’s

N/A  

1

2

3

4

Maintenance of IV’s

N/A  

1

2

3

4

Administration of IV meds

N/A  

1

2

3

4

Calculate drip rates

N/A  

1

2

3

4

Insertion of heparin lock

N/A  

1

2

3

4

Care/maintenance of central lines

N/A  

1

2

3

4

 

INFECTIOUS DISEASES

Fever management

N/A  

1

2

3

4

AIDS

N/A  

1

2

3

4

Cytomegalo virus (CMV)

N/A  

1

2

3

4

Hepatitis

N/A  

1

2

3

4

Kawasaki disease

N/A  

1

2

3

4

Lyme disease

N/A  

1

2

3

4

 

WOUND AND SKIN CARE

Decubitis ulcers

N/A  

1

2

3

4

Pressure sores

N/A  

1

2

3

4

Surgical incisions with drains (i.e. JP drain)

N/A  

1

2

3

4

Sterile dressing changes

N/A  

1

2

3

4

Traumatic wound care

N/A  

1

2

3

4

Wound irrigations

N/A  

1

2

3

4

 

OTHER NURSING RESPONSIBILITIES

Charge nurse experience

N/A  

1

2

3

4

Assess normal growth and development

N/A  

1

2

3

4

Recognize signs of abuse or neglect

N/A  

1

2

3

4

Immunization schedule

N/A  

1

2

3

4

Calculation of pediatric medication doses

N/A  

1

2

3

4

Eye/ear instillations

N/A  

1

2

3

4

Knowledge of emergency drugs

N/A  

1

2

3

4

Metered dose inhaler

N/A  

1

2

3

4

Assessment of pain level/tolerance

N/A  

1

2

3

4

Epidural anesthesia/analgesia

N/A  

1

2

3

4

IV conscious sedation

N/A  

1

2

3

4

Narcotic analgesia

N/A  

1

2

3

4

Anorexia/bulimia

N/A  

1

2

3

4

Craniofacial reconstruction

N/A  

1

2

3

4

Depression

N/A  

1

2

3

4

ENT surgery

N/A  

1

2

3

4

Eye surgery

N/A  

1

2

3

4

Ingestion of foreign body

N/A  

1

2

3

4

Ingestion of poison or toxins

N/A  

1

2

3

4

Suicidal threats/actions

N/A  

1

2

3

4

Infant (30 days-1 year)

N/A  

1

2

3

4

Toddler (1-3 years)

N/A  

1

2

3

4

Pre-schooler (3-5 years)

N/A  

1

2

3

4

School age (5-12 years)

N/A  

1

2

3

4

Adolescents (12-18 years)

N/A  

1

2

3

4