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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:  
        NALS:  
        NRP:  
        RNC:  
        NCC:
 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

ALabor and Delivery

Cervical dilation and changes

N/A  

1

2

3

4

Cervical effacement and changes

N/A  

1

2

3

4

Duration, frequency, and quality of contractions

N/A  

1

2

3

4

Vaginal delivery

N/A  

1

2

3

4

Forceps vaginal delivery/vacuum extraction delivery

N/A  

1

2

3

4

Emergency delivery

N/A  

1

2

3

4

High risk delivery

N/A  

1

2

3

4

Placement of intrauterine pressure catheter

N/A  

1

2

3

4

Fetal scalp blood sampling procedure

N/A  

1

2

3

4

Artificial rupture of membranes procedure

N/A  

1

2

3

4

Vaginal exam

N/A  

1

2

3

4

Fundal assessment/height

N/A  

1

2

3

4

Use of fetalscope/doppler

N/A  

1

2

3

4

Interpretation of fetal monitoring

N/A  

1

2

3

4

Internal monitor/lead connection and calibration

N/A  

1

2

3

4

Foley catheter insertion or straight catheterization (cath)

N/A  

1

2

3

4

Perineal prep

N/A  

1

2

3

4

Abdominal shave/scrub prep

N/A  

1

2

3

4

Circulate for C-section

N/A  

1

2

3

4

Scrub for C-section

N/A  

1

2

3

4

Abruptio placenta

N/A  

1

2

3

4

Diabetes mellitus

N/A  

1

2

3

4

Infectious disease

N/A  

1

2

3

4

Malpresentations

N/A  

1

2

3

4

Multiple gestation

N/A  

1

2

3

4

Pregnancy-induced hypertension

N/A  

1

2

3

4

Preeclampsia

N/A  

1

2

3

4

Placenta previa

N/A  

1

2

3

4

Premature labor

N/A  

1

2

3

4

Prolapsed cord

N/A  

1

2

3

4

RH incompatibilities

N/A  

1

2

3

4

Sickle cell crisis

N/A  

1

2

3

4

Cytotec

N/A  

1

2

3

4

Prostaglandin

N/A  

1

2

3

4

Insulin drips

N/A  

1

2

3

4

Magnesium Sulfate

N/A  

1

2

3

4

Ritodrine

N/A  

1

2

3

4

Pitocin

N/A  

1

2

3

4

 

IV Therapy

Start/maintenance of peripheral IV’s

N/A  

1

2

3

4

Use of saline/heparin lock

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

 

Postpartum Care

Bladder status

N/A  

1

2

3

4

Episiotomy

N/A  

1

2

3

4

Fundal consistency and height

N/A  

1

2

3

4

Lochia amount and character

N/A  

1

2

3

4

Assess and foster parent-infant bonding

N/A  

1

2

3

4

Assist with breast feeding

N/A  

1

2

3

4

Bladder care

N/A  

1

2

3

4

Bowel care

N/A  

1

2

3

4

Breast care

N/A  

1

2

3

4

Fundal massage

N/A  

1

2

3

4

Perineal care

N/A  

1

2

3

4

Post C-section care

N/A  

1

2

3

4

Post-anesthesia recovery care (epidural, spinal and general)

N/A  

1

2

3

4

 

Newborn care

Assign Apgar score

N/A  

1

2

3

4

Basic physical exam of newborn (Anomalies and respiratory status)

N/A  

1

2

3

4

Eye prophylaxis

N/A  

1

2

3

4

Suction newborn

N/A  

1

2

3

4

Collection of cord blood samples

N/A  

1

2

3

4

Transfer to newborn nursery

N/A  

1

2

3

4

Use of radiant warmers

N/A  

1

2

3

4

Apnea monitoring

N/A  

1

2

3

4

Phototherapy

N/A  

1

2

3

4

Circumcision care

N/A  

1

2

3

4

Umbilical cord care

N/A  

1

2

3

4