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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.
 
 
 
   
 
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   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

General Surgery: Circulate

Appendectomy

N/A  

1

2

3

4

Breast Biopsy

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Abdominal-Perineal Resection

N/A  

1

2

3

4

Bowel/Colon Resection

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Thyroidectomy

N/A  

1

2

3

4

Splenectomy

N/A  

1

2

3

4

Vein Stripping

N/A  

1

2

3

4

Radical Mastectomy

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Gastrectomy

N/A  

1

2

3

4

Hickman/Groshong/Portacath Insertion

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Bowel

N/A  

1

2

3

4

Nissen

N/A  

1

2

3

4

Bariatric

N/A  

1

2

3

4

 

General Surgery: Scrub

Appendectomy

N/A  

1

2

3

4

Breast Biopsy

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Abdominal-Perineal Resection

N/A  

1

2

3

4

Bowel/Colon Resection

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Thyroidectomy

N/A  

1

2

3

4

Splenectomy

N/A  

1

2

3

4

Vein Stripping

N/A  

1

2

3

4

Radical Mastectomy

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Gastrectomy

N/A  

1

2

3

4

Hickman/Groshong/Portacath Insertion

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Bowel

N/A  

1

2

3

4

Nissen

N/A  

1

2

3

4

Bariatric

N/A  

1

2

3

4

 

Thoracic/CV: Circulate

Abdominal Aortic Aneurysm

N/A  

1

2

3

4

Aortic-Femoral Bypass Graft

N/A  

1

2

3

4

AV Shunt/Graft

N/A  

1

2

3

4

Carotid Endarterectomy

N/A  

1

2

3

4

Lobectomy

N/A  

1

2

3

4

Mediastinoscopy

N/A  

1

2

3

4

Thoracoscopy

N/A  

1

2

3

4

Thoracotomy

N/A  

1

2

3

4

 

Thoracic/CV: Scrub

Abdominal Aortic Aneurysm

N/A  

1

2

3

4

Aortic-Femoral Bypass Graft

N/A  

1

2

3

4

AV Shunt/Graft

N/A  

1

2

3

4

Carotid Endarterectomy

N/A  

1

2

3

4

Lobectomy

N/A  

1

2

3

4

Mediastinoscopy

N/A  

1

2

3

4

Thoracoscopy

N/A  

1

2

3

4

Thoracotomy

N/A  

1

2

3

4

 

Orthopedic/Podiatry: Circulate

Knee Arthroscopy

N/A  

1

2

3

4

ACL Repair

N/A  

1

2

3

4

Shoulder Arthroscopy

N/A  

1

2

3

4

Endoscopic Shoulder Repair

N/A  

1

2

3

4

Open Shoulder Repair

N/A  

1

2

3

4

Total Knee Replacement/Revision

N/A  

1

2

3

4

Total Hip Replacement/Revision

N/A  

1

2

3

4

Bipolar Hip Replacement

N/A  

1

2

3

4

Hip Compression Nails and Lag Screw

N/A  

1

2

3

4

Hand Surgery

N/A  

1

2

3

4

External Fixation Devices

N/A  

1

2

3

4

IM Roddings

N/A  

1

2

3

4

Bunionectomy

N/A  

1

2

3

4

Spinal Fusion With Instrumentation

N/A  

1

2

3

4

Harrington Rod Insertion

N/A  

1

2

3

4

Carpal Tunnel Repair

N/A  

1

2

3

4

Chick Fracture Table

N/A  

1

2

3

4

ORIF With Compression Set

N/A  

1

2

3

4

Closed Reduction Fracture

N/A  

1

2

3

4

 

Orthopedic/Podiatry: Scrub

Knee Arthroscopy

N/A  

1

2

3

4

ACL Repair

N/A  

1

2

3

4

Shoulder Arthroscopy

N/A  

1

2

3

4

Endoscopic Shoulder Repair

N/A  

1

2

3

4

Open Shoulder Repair

N/A  

1

2

3

4

Total Knee Replacement/Revision

N/A  

1

2

3

4

Total Hip Replacement/Revision

N/A  

1

2

3

4

Bipolar Hip Replacement

N/A  

1

2

3

4

Hip Compression Nails and Lag Screw

N/A  

1

2

3

4

Hand Surgery

N/A  

1

2

3

4

External Fixation Devices

N/A  

1

2

3

4

IM Roddings

N/A  

1

2

3

4

Bunionectomy

N/A  

1

2

3

4

Spinal Fusion With Instrumentation

N/A  

1

2

3

4

Harrington Rod Insertion

N/A  

1

2

3

4

Carpal Tunnel Repair

N/A  

1

2

3

4

Chick Fracture Table

N/A  

1

2

3

4

ORIF With Compression Set

N/A  

1

2

3

4

Closed Reduction Fracture

N/A  

1

2

3

4

 

Neurosurgery: Circulate

Cervical Laminectomy (Anterior)

N/A  

1

2

3

4

Cervical Laminectomy (Posterior)

N/A  

1

2

3

4

Lumbar Laminectomy

N/A  

1

2

3

4

VP Shunt (Ventricualr-Peitoneal)

N/A  

1

2

3

4

Craniotomy

N/A  

1

2

3

4

Burr Holes (Sub-Dural Hematoma)

N/A  

1

2

3

4

 

Neurosurgery: Scrub

Cervical Laminectomy (Anterior)

N/A  

1

2

3

4

Cervical Laminectomy (Posterior)

N/A  

1

2

3

4

Lumbar Laminectomy

N/A  

1

2

3

4

VP Shunt (Ventricualr-Peitoneal)

N/A  

1

2

3

4

Craniotomy

N/A  

1

2

3

4

Burr Holes (Sub-Dural Hematoma)

N/A  

1

2

3

4

 

Plastic/Reconstructive Surgery: Circulate

Abdominoplasty

N/A  

1

2

3

4

Facelift

N/A  

1

2

3

4

Skin Grafts

N/A  

1

2

3

4

Breast Reconstruction

N/A  

1

2

3

4

Breast Augmentation

N/A  

1

2

3

4

Breast Reduction

N/A  

1

2

3

4

Rhinoplasty

N/A  

1

2

3

4

Cleft Palate Repair

N/A  

1

2

3

4

Liposuction

N/A  

1

2

3

4

Blepharoplasty

N/A  

1

2

3

4

Tissue Expanders

N/A  

1

2

3

4

 

Plastic/Reconstructive Surgery: Scrub

Abdominoplasty

N/A  

1

2

3

4

Facelift

N/A  

1

2

3

4

Skin Grafts

N/A  

1

2

3

4

Breast Reconstruction

N/A  

1

2

3

4

Breast Augmentation

N/A  

1

2

3

4

Breast Reduction

N/A  

1

2

3

4

Rhinoplasty

N/A  

1

2

3

4

Cleft Palate Repair

N/A  

1

2

3

4

Liposuction

N/A  

1

2

3

4

Blepharoplasty

N/A  

1

2

3

4

Tissue Expanders

N/A  

1

2

3

4

 

Opthalmology: Circulate

Cataract Extraction with IOL

N/A  

1

2

3

4

Corneal Transplant

N/A  

1

2

3

4

Dacryocystectomy

N/A  

1

2

3

4

Phaco Emulsification

N/A  

1

2

3

4

Orbital Implant

N/A  

1

2

3

4

Enucleation

N/A  

1

2

3

4

Vitrectomy

N/A  

1

2

3

4

Scleral Buckle

N/A  

1

2

3

4

Muscle Procedures

N/A  

1

2

3

4

 

Opthalmology: Scrub

Cataract Extraction with IOL

N/A  

1

2

3

4

Corneal Transplant

N/A  

1

2

3

4

Dacryocystectomy

N/A  

1

2

3

4

Phaco Emulsification

N/A  

1

2

3

4

Orbital Implant

N/A  

1

2

3

4

Enucleation

N/A  

1

2

3

4

Vitrectomy

N/A  

1

2

3

4

Scleral Buckle

N/A  

1

2

3

4

Muscle Procedures

N/A  

1

2

3

4

 

ENT/Oral Surgery: Circulate

Bronchoscopy

N/A  

1

2

3

4

T&A

N/A  

1

2

3

4

Myringotomy

N/A  

1

2

3

4

Stapedectomy

N/A  

1

2

3

4

Tympanoplasty

N/A  

1

2

3

4

Sinus Endoscopy

N/A  

1

2

3

4

Septoplasty

N/A  

1

2

3

4

Parotidectomy

N/A  

1

2

3

4

TMJ

N/A  

1

2

3

4

Jaw Fractures

N/A  

1

2

3

4

Mini AO Compression

N/A  

1

2

3

4

 

ENT/Oral Surgery: Scrub

Bronchoscopy

N/A  

1

2

3

4

T&A

N/A  

1

2

3

4

Myringotomy

N/A  

1

2

3

4

Stapedectomy

N/A  

1

2

3

4

Tympanoplasty

N/A  

1

2

3

4

Sinus Endoscopy

N/A  

1

2

3

4

Septoplasty

N/A  

1

2

3

4

Parotidectomy

N/A  

1

2

3

4

TMJ

N/A  

1

2

3

4

Jaw Fractures

N/A  

1

2

3

4

Mini AO Compression

N/A  

1

2

3

4

 

Urology and Cysto: Circulate

Nephrectomy

N/A  

1

2

3

4

Prostatectomy

N/A  

1

2

3

4

Vasectomy

N/A  

1

2

3

4

Cystectomy

N/A  

1

2

3

4

Penile Prosthesis

N/A  

1

2

3

4

TURP

N/A  

1

2

3

4

Cystoscopy/Ureteroscopy

N/A  

1

2

3

4

Lithotripsy

N/A  

1

2

3

4

Hypospadias Repair

N/A  

1

2

3

4

Orchiopexy

N/A  

1

2

3

4

 

Urology and Cysto: Scrub

Nephrectomy

N/A  

1

2

3

4

Prostatectomy

N/A  

1

2

3

4

Vasectomy

N/A  

1

2

3

4

Cystectomy

N/A  

1

2

3

4

Penile Prosthesis

N/A  

1

2

3

4

TURP

N/A  

1

2

3

4

Cystoscopy/Ureteroscopy

N/A  

1

2

3

4

Lithotripsy

N/A  

1

2

3

4

Hypospadias Repair

N/A  

1

2

3

4

Orchiopexy

N/A  

1

2

3

4

 

GYN Surgery: Circulate

AP Repair (Anterior and Posterior)

N/A  

1

2

3

4

D&C

N/A  

1

2

3

4

LEEP (Loop Electrode Excision Repair)

N/A  

1

2

3

4

Abdominal Hysterectomy

N/A  

1

2

3

4

Vaginal Hysterectomy

N/A  

1

2

3

4

Laparoscopy

N/A  

1

2

3

4

Laparoscopic Tubal Ligation

N/A  

1

2

3

4

Laser Vaporization Condyloma

N/A  

1

2

3

4

MMK (Marshall Marchetti Krantz)

N/A  

1

2

3

4

Tubal Ligation

N/A  

1

2

3

4

Hysteroscopy

N/A  

1

2

3

4

 

GYN Surgery: Scrub

AP Repair (Anterior and Posterior)

N/A  

1

2

3

4

D&C

N/A  

1

2

3

4

LEEP (Loop Electrode Excision Repair)

N/A  

1

2

3

4

Abdominal Hysterectomy

N/A  

1

2

3

4

Vaginal Hysterectomy

N/A  

1

2

3

4

Laparoscopy

N/A  

1

2

3

4

Laparoscopic Tubal Ligation

N/A  

1

2

3

4

Laser Vaporization Condyloma

N/A  

1

2

3

4

MMK (Marshall Marchetti Krantz)

N/A  

1

2

3

4

Tubal Ligation

N/A  

1

2

3

4

Hysteroscopy

N/A  

1

2

3

4

 

Pediatrics: Circulate

Exploratory Laparotomy

N/A  

1

2

3

4

Otoplasty

N/A  

1

2

3

4

Circumcision

N/A  

1

2

3

4

Hypospadias Repair

N/A  

1

2

3

4

Herniorrhaphy

N/A  

1

2

3

4

Cleft lip/Palate

N/A  

1

2

3

4

 

Pediatrics: Scrub

Exploratory Laparotomy

N/A  

1

2

3

4

Otoplasty

N/A  

1

2

3

4

Circumcision

N/A  

1

2

3

4

Hypospadias Repair

N/A  

1

2

3

4

Herniorrhaphy

N/A  

1

2

3

4

Cleft lip/Palate

N/A  

1

2

3

4

 

Open Heart Surgery: Circulate

CABG

N/A  

1

2

3

4

ASD(Atrial Septal Defect)

N/A  

1

2

3

4

VSD (Ventral Septal Defect)

N/A  

1

2

3

4

Mitral or Aortic Valve Replacement

N/A  

1

2

3

4

Tetrology of Fallot

N/A  

1

2

3

4

Emergent Bring Back Heart

N/A  

1

2

3

4

 

Open Heart Surgery: Scrub

CABG

N/A  

1

2

3

4

ASD(Atrial Septal Defect)

N/A  

1

2

3

4

VSD (Ventral Septal Defect)

N/A  

1

2

3

4

Mitral or Aortic Valve Replacement

N/A  

1

2

3

4

Tetrology of Fallot

N/A  

1

2

3

4

Emergent Bring Back Heart

N/A  

1

2

3

4

 

Transplants: Circulate

Kidney Transplant Recipient

N/A  

1

2

3

4

Kidney Transplant Donor

N/A  

1

2

3

4

Heart Transplant

N/A  

1

2

3

4

Liver Transplant

N/A  

1

2

3

4

Lung Transplant

N/A  

1

2

3

4

Multi-Organ (Harvest)

N/A  

1

2

3

4

 

Transplants: Scrub

Kidney Transplant Recipient

N/A  

1

2

3

4

Kidney Transplant Donor

N/A  

1

2

3

4

Heart Transplant

N/A  

1

2

3

4

Liver Transplant

N/A  

1

2

3

4

Lung Transplant

N/A  

1

2

3

4

Multi-Organ (Harvest)

N/A  

1

2

3

4