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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

       Certifications: (Check all that apply)

        BLS/BCLS/CPR:    
        ACLS:    
        TNCC:    
        TNS:    
        CEN:
        MAB:    
        PALS:
        ENPC:
 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Cardiovascular

Obtain 12 lead EKG

N/A  

1

2

3

4

Basic 12 lead interpretation

N/A  

1

2

3

4

Basic arrhythmia interpretation

N/A  

1

2

3

4

Heart sounds and murmurs

N/A  

1

2

3

4

Heart rate and rhythm

N/A  

1

2

3

4

Presence and characteristics of chest pain

N/A  

1

2

3

4

CPR

N/A  

1

2

3

4

Cardioversion/Defibrillation

N/A  

1

2

3

4

ABG’s

N/A  

1

2

3

4

Electrolytes

N/A  

1

2

3

4

Cardiac enzymes

N/A  

1

2

3

4

Acute MI

N/A  

1

2

3

4

Angina

N/A  

1

2

3

4

Cardiac arrest

N/A  

1

2

3

4

Congestive heart failure (CHF)

N/A  

1

2

3

4

Use of cardiac monitor

N/A  

1

2

3

4

Use of doppler

N/A  

1

2

3

4

Atropine

N/A  

1

2

3

4

Digoxin (Lanoxin)

N/A  

1

2

3

4

Epinephrine (Adrenalin)

N/A  

1

2

3

4

Lidocaine (Xylocaine)

N/A  

1

2

3

4

Sodium Bicarbonate

N/A  

1

2

3

4

 

Pulmonary

Assessment of breath sounds

N/A  

1

2

3

4

Airway management and suctioning:

N/A  

1

2

3

4

Endotracheal tube

N/A  

1

2

3

4

Nasal airway

N/A  

1

2

3

4

Oropharyngeal

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Care of the patient with a chest tube

N/A  

1

2

3

4

Sputum specimen collection

N/A  

1

2

3

4

Set up and assist with intubation

N/A  

1

2

3

4

Assist with extubation

N/A  

1

2

3

4

Assist with thoracentesis

N/A  

1

2

3

4

Care of the patient on a ventilator

N/A  

1

2

3

4

Ambu bag

N/A  

1

2

3

4

Face masks

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Trach Collar

N/A  

1

2

3

4

Aspiration

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

Pneumonia

N/A  

1

2

3

4

Pneumothorax

N/A  

1

2

3

4

Pulmonary embolism

N/A  

1

2

3

4

Tuberculosis

N/A  

1

2

3

4

 

Neurological

Assess cranial nerves

N/A  

1

2

3

4

Assess reflex/motor deficits

N/A  

1

2

3

4

Assess visual or communication deficits

N/A  

1

2

3

4

Use of Glasgow coma scale

N/A  

1

2

3

4

Assist with lumbar puncture

N/A  

1

2

3

4

Intracranial pressure (ICP)monitoring

N/A  

1

2

3

4

Closed head injury

N/A  

1

2

3

4

Acute CVA

N/A  

1

2

3

4

DTs (Delirium tremors)

N/A  

1

2

3

4

Overdose

N/A  

1

2

3

4

Seizure disorders

N/A  

1

2

3

4

Spinal cord injury

N/A  

1

2

3

4

 

Orthopedics

Circulation checks

N/A  

1

2

3

4

Assist with cast application

N/A  

1

2

3

4

Splints

N/A  

1

2

3

4

Pinned fractures

N/A  

1

2

3

4

 

GI/GU and Renal

Insertion of NG tube/lavage

N/A  

1

2

3

4

Insertion and care of Foley catheter

N/A  

1

2

3

4

Abdominal trauma

N/A  

1

2

3

4

Appendicitis

N/A  

1

2

3

4

Bowel obstruction

N/A  

1

2

3

4

GI bleeding

N/A  

1

2

3

4

Hepatitis

N/A  

1

2

3

4

Liver failure

N/A  

1

2

3

4

Acute renal failure

N/A  

1

2

3

4

Renal trauma

N/A  

1

2

3

4

UTI (Urinary tract infection)

N/A  

1

2

3

4

 

Trauma/Shock

Animal bites

N/A  

1

2

3

4

Human bites

N/A  

1

2

3

4

Knowledge of rabies vaccination/antivenom administration protocols

N/A  

1

2

3

4

Burns

N/A  

1

2

3

4

Dehydration

N/A  

1

2

3

4

Electrocution

N/A  

1

2

3

4

Gunshot/stab wound

N/A  

1

2

3

4

Hazardous material exposure

N/A  

1

2

3

4

Heat exhaustion/stroke

N/A  

1

2

3

4

Hypothermia

N/A  

1

2

3

4

Major trauma

N/A  

1

2

3

4

Minor trauma

N/A  

1

2

3

4

Multiple fractures

N/A  

1

2

3

4

Radiation exposure

N/A  

1

2

3

4

Shock

N/A  

1

2

3

4

Traumatic amputation

N/A  

1

2

3

4

 

IV Therapy

Start peripheral IV’s

N/A  

1

2

3

4

Use of saline/heparin lock

N/A  

1

2

3

4

Administration/mixing of IV meds

N/A  

1

2

3

4

Administration of IV fluids

N/A  

1

2

3

4

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

N/A  

1

2

3

4

Hang IV piggybacks

N/A  

1

2

3

4

Use of infusion pumps

N/A  

1

2

3

4

IV calculations/titrate drip rates

N/A  

1

2

3

4

Knowledge of access and maintenance of central lines and catheters

N/A  

1

2

3

4

 

Pediatrics

Recognizing and reporting child abuse/neglect

N/A  

1

2

3

4

Pediatric cardiac arrest

N/A  

1

2

3

4

Epiglottitis

N/A  

1

2

3

4

Near drowning

N/A  

1

2

3

4

Overdose/poison ingestion

N/A  

1

2

3

4

Failure to thrive

N/A  

1

2

3

4

Seizure/epilepsy

N/A  

1

2

3

4

 

Additional nursing responsibilities

Charge nurse

N/A  

1

2

3

4

Triage

N/A  

1

2

3

4

Universal precautions

N/A  

1

2

3

4

Lab value interpretation (CBC, SMA 7)

N/A  

1

2

3

4

Suicide precautions

N/A  

1

2

3

4

Violent patient

N/A  

1

2

3

4

Use of restraints

N/A  

1

2

3

4

Rape victim

N/A  

1

2

3

4

STD’s

N/A  

1

2

3

4

Identify signs/symptoms of physical or sexual abuse and take appropriate actions

N/A  

1

2

3

4

Antepartum/postpartum complications

N/A  

1

2

3

4

Collection and handling of lab specimens (blood, nasopharyngeal, stool, urine, wound)

N/A  

1

2

3

4

Administer IM, SQ, topical, and inhalent medications

N/A  

1

2

3

4

Identify adverse effects, signs and symptoms of toxicity, and effectiveness of medication

N/A  

1

2

3

4

Calculate medication dosages

N/A  

1

2

3

4

Care of the patient with diabetic ketoacidosis

N/A  

1

2

3

4

Recognize signs and symptoms of diabetic reaction (hypoglycemia)

N/A  

1

2

3

4

Blood glucose monitoring

N/A  

1

2

3

4

Insulin administration

N/A  

1

2

3

4

Care of the patient with AIDS

N/A  

1

2

3

4

Knowledge of isolation techniques/procedures

N/A  

1

2

3

4

Aware of Health Department/CDC requirements for reporting communicable diseases

N/A  

1

2

3

4