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    *required fields

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:  
   

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Cardiovascular

Arrhythmia interpretation

N/A  

1

2

3

4

Heart Sounds interpretation

N/A  

1

2

3

4

Placement of patient on cardiac monitor

N/A  

1

2

3

4

Basic 12 lead ECG interpretation

N/A  

1

2

3

4

Defibrillation/cardioversion

N/A  

1

2

3

4

Temporary external pacing

N/A  

1

2

3

4

Temporary transvenous

N/A  

1

2

3

4

Temporary epicardial wires

N/A  

1

2

3

4

Permanent

N/A  

1

2

3

4

Swan Ganz hemodynamic monitoring

N/A  

1

2

3

4

Central venous catheter

N/A  

1

2

3

4

Arterial line (A-line)

N/A  

1

2

3

4

Use of Doppler

N/A  

1

2

3

4

Post open heart patient

N/A  

1

2

3

4

Heart transplant patient

N/A  

1

2

3

4

Pre/post cardiac patient

N/A  

1

2

3

4

24-48 hours post MI patient

N/A  

1

2

3

4

CHF patient (congestive heart failure)

N/A  

1

2

3

4

Carotid endarterectomy patient

N/A  

1

2

3

4

Fem-pop bypass patient (femoral-popliteal)

N/A  

1

2

3

4

Dobutamine

N/A  

1

2

3

4

Dopamine

N/A  

1

2

3

4

Epinephrine

N/A  

1

2

3

4

Heparin

N/A  

1

2

3

4

Lidocaine

N/A  

1

2

3

4

Nitroglycerine (Nitro)

N/A  

1

2

3

4

Pronestyl

N/A  

1

2

3

4

 

Pulmonary

Assist with extubation

N/A  

1

2

3

4

Assist with intubation

N/A  

1

2

3

4

Chest physiotherapy

N/A  

1

2

3

4

Assessment of breath sounds

N/A  

1

2

3

4

Monitor pulse oximetry

N/A  

1

2

3

4

Ventilator management

N/A  

1

2

3

4

Interpretation of ABG’s

N/A  

1

2

3

4

Administration of nebulizer medications

N/A  

1

2

3

4

Oropharyngeal suctioning

N/A  

1

2

3

4

Nasotracheal suctioning

N/A  

1

2

3

4

Assist with thoracentesis

N/A  

1

2

3

4

Set up and assist with chest tube insertion and removal

N/A  

1

2

3

4

Chest tubes

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

Lobectomy

N/A  

1

2

3

4

Thoracotomy

N/A  

1

2

3

4

Lung transplant

N/A  

1

2

3

4

Aspiration

N/A  

1

2

3

4

Laryngospasm

N/A  

1

2

3

4

Pulmonary edema

N/A  

1

2

3

4

Tension pneumothorax

N/A  

1

2

3

4

 

Neuro

Assess LOC

N/A  

1

2

3

4

Use Glascow coma scale

N/A  

1

2

3

4

Cranial nerve assessment

N/A  

1

2

3

4

Seizure precautions

N/A  

1

2

3

4

Halo traction

N/A  

1

2

3

4

Cervical traction

N/A  

1

2

3

4

Assist with lumbar punctures

N/A  

1

2

3

4

Hypo/hyperthermia regulation

N/A  

1

2

3

4

CVA

N/A  

1

2

3

4

Closed head injury

N/A  

1

2

3

4

Overdose

N/A  

1

2

3

4

Spinal cord injury

N/A  

1

2

3

4

Pre/post neuro surgery

N/A  

1

2

3

4

 

Gastrointestinal

Assessment of abdomen

N/A  

1

2

3

4

Care of patient with GI bleed

N/A  

1

2

3

4

Care of GI surgical patient

N/A  

1

2

3

4

Administration of tube feedings

N/A  

1

2

3

4

Placement of NG tube

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

Blood/blood products administration: precautions/recognizing transfusion reactions/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

 

Other Nursing Responsibilities

Charge nurse responsibilities

N/A  

1

2

3

4

Drawing venous blood

N/A  

1

2

3

4

Drawing arterial blood

N/A  

1

2

3

4

Interpret lab values for electrolyte imbalances

N/A  

1

2

3

4

Isolation procedures/precautions

N/A  

1

2

3

4

Wound and skin care

N/A  

1

2

3

4

Use of restraints

N/A  

1

2

3

4

Oncology/chemotherapy administration

N/A  

1

2

3

4

Blood glucose monitoring

N/A  

1

2

3

4

Insulin administration

N/A  

1

2

3

4

Assess for signs and symptoms of insulin shock/diabetic coma

N/A  

1

2

3

4