Name*
First
Last
Age Specific Care
Proficiency Rating
Frequency Rating
Newborn/Neonate (birth - 30 days) *
Newborn/Neonate (birth - 30 days) proficiency* Newborn/Neonate (birth - 30 days) frequency* Infant (30 days - 1 year) *
Infant (30 days - 1 year) proficiency* Infant (30 days - 1 year) frequency* Toddler (1 - 3 years) *
Toddler (1 - 3 years) proficiency* Toddler (1 - 3 years) frequency* Preschooler (3 - 5 years) *
Preschooler (3 - 5 years) proficiency* Preschooler (3 - 5 years) frequency* School Age Child (5 - 12 years) *
School Age Child (5 - 12 years) proficiency* School Age Child (5 - 12 years) frequency* Adolescents (12 - 18 years) *
Adolescents (12 - 18 years) proficiency* Adolescents (12 - 18 years) frequency* Young Adults (18 - 39 years) *
Young Adults (18 - 39 years) proficiency* Young Adults (18 - 39 years) frequency* Middle Adults (39 - 64 years) *
Middle Adults (39 - 64 years) proficiency* Middle Adults (39 - 64 years) frequency* Older Adults (64+ years) *
Older Adults (64+ years) proficiency* Older Adults (64+ years) frequency* Elderly Adults (over 79+ years) *
Elderly Adults (over 79+ years) proficiency* Elderly Adults (over 79+ years) frequency*
General Skills
Proficiency Rating
Frequency Rating
Standard Precautions *
Standard Precautions proficiency* Standard Precautions frequency* Isolation Precautions *
Isolation Precautions proficiency* Isolation Precautions frequency* Pediatric Respiratory / Cardiac Arrest *
Pediatric Respiratory / Cardiac Arrest proficiency* Pediatric Respiratory / Cardiac Arrest frequency* Adult Respiratory / Cardiac Arrest *
Adult Respiratory / Cardiac Arrest proficiency* Adult Respiratory / Cardiac Arrest frequency* Crash Carts *
Crash Carts proficiency* Crash Carts frequency* Defibrillators *
Defibrillators proficiency* Defibrillators frequency* Care of Patient in Restraints *
Care of Patient in Restraints proficiency* Care of Patient in Restraints frequency* Pain Management *
Pain Management proficiency* Pain Management frequency* Automated Med Dispensing Systems *
Automated Med Dispensing Systems proficiency* Automated Med Dispensing Systems frequency* Patient / Family Education *
Patient / Family Education proficiency* Patient / Family Education frequency* Electronic Documentation *
Electronic Documentation proficiency* Electronic Documentation frequency* Patient Head to Toe Assessment *
Patient Head to Toe Assessment proficiency* Patient Head to Toe Assessment frequency* Knowledge of Normal Serum Lab Values *
Knowledge of Normal Serum Lab Values proficiency* Knowledge of Normal Serum Lab Values frequency* Obtaining Cultures (Blood, Sputum, Swab) *
Obtaining Cultures (Blood, Sputum, Swab) proficiency* Obtaining Cultures (Blood, Sputum, Swab) frequency* Administration of Blood and Blood Products *
Administration of Blood and Blood Products proficiency* Administration of Blood and Blood Products frequency* PCA Pumps *
PCA Pumps proficiency* PCA Pumps frequency* Infusion Pumps *
Infusion Pumps proficiency* Infusion Pumps frequency* Calculate mcg / min and mcg / kg / min *
Calculate mcg / min and mcg / kg / min proficiency* Calculate mcg / min and mcg / kg / min frequency* Titrating Medications *
Titrating Medications proficiency* Titrating Medications frequency* Moderate / Conscious Sedation & Reversal Agents *
Moderate / Conscious Sedation & Reversal Agents proficiency* Moderate / Conscious Sedation & Reversal Agents frequency*
IV Therapy
Proficiency Rating
Frequency Rating
Initiate Peripheral IV *
Initiate Peripheral IV proficiency* Initiate Peripheral IV frequency* Discontinue Peripheral IV *
Discontinue Peripheral IV proficiency* Discontinue Peripheral IV frequency* Central Line Blood Draw *
Central Line Blood Draw proficiency* Central Line Blood Draw frequency* Central Line Care & Maintenance *
Central Line Care & Maintenance proficiency* Central Line Care & Maintenance frequency* PICC Line Blood Draw *
PICC Line Blood Draw proficiency* PICC Line Blood Draw frequency* PICC Line Care & Maintenance *
PICC Line Care & Maintenance proficiency* PICC Line Care & Maintenance frequency*
Neuro General Skills
Proficiency Rating
Frequency Rating
Assessment of Neuro Signs *
Assessment of Neuro Signs proficiency* Assessment of Neuro Signs frequency* Glasgow Coma Scale *
Glasgow Coma Scale proficiency* Glasgow Coma Scale frequency* Seizure Precautions *
Seizure Precautions proficiency* Seizure Precautions frequency* Assist with Lumbar Puncture *
Assist with Lumbar Puncture proficiency* Assist with Lumbar Puncture frequency* Halo Traction *
Halo Traction proficiency* Halo Traction frequency* NEURO - CARE OF PATIENTS WITH:
CVA *
CVA proficiency* CVA frequency* Seizure Activity *
Seizure Activity proficiency* Seizure Activity frequency* Overdose *
Overdose proficiency* Overdose frequency* Neuro / Head Injury / Trauma *
Neuro / Head Injury / Trauma proficiency* Neuro / Head Injury / Trauma frequency* Pre / Post Neuro Surgery *
Pre / Post Neuro Surgery proficiency* Pre / Post Neuro Surgery frequency* Cranial Hemorrhage *
Cranial Hemorrhage proficiency* Cranial Hemorrhage frequency* Multiple Sclerosis *
Multiple Sclerosis proficiency* Multiple Sclerosis frequency* Post-Op AV Shunt *
Post-Op AV Shunt proficiency* Post-Op AV Shunt frequency*
Medication Knowledge and Use of
Proficiency Rating
Frequency Rating
Decadron *
Decadron proficiency* Decadron frequency* Dilantin *
Dilantin proficiency* Dilantin frequency* Magnesium Sulfate *
Magnesium Sulfate proficiency* Magnesium Sulfate frequency* Phenobarbital *
Phenobarbital proficiency* Phenobarbital frequency* Steroids *
Steroids proficiency* Steroids frequency* Valium *
Valium proficiency* Valium frequency* Versed *
Versed proficiency* Versed frequency*
Cardiac General Skills
Proficiency Rating
Frequency Rating
Auscultation of Cardiac Sounds *
Auscultation of Cardiac Sounds proficiency* Auscultation of Cardiac Sounds frequency* Dopplers *
Dopplers proficiency* Dopplers frequency* Interpretation of 12 lead EKG *
Interpretation of 12 lead EKG proficiency* Interpretation of 12 lead EKG frequency* Interpretation of Arrhythmias *
Interpretation of Arrhythmias proficiency* Interpretation of Arrhythmias frequency* Defibrillation / cardioversion *
Defibrillation / cardioversion proficiency* Defibrillation / cardioversion frequency* Permanent Pacemaker *
Permanent Pacemaker proficiency* Permanent Pacemaker frequency* Temporary Pacemaker *
Temporary Pacemaker proficiency* Temporary Pacemaker frequency* AICD *
AICD proficiency* AICD frequency* Art - Line (transducer set - up, D/C) *
Art - Line (transducer set - up, D/C) proficiency* Art - Line (transducer set - up, D/C) frequency* Sheath Removal *
Sheath Removal proficiency* Sheath Removal frequency* Interpretation of Cardiac Enzymes *
Interpretation of Cardiac Enzymes proficiency* Interpretation of Cardiac Enzymes frequency*
Cardiac - Care of Patients with
Proficiency Rating
Frequency Rating
Angina *
Angina proficiency* Angina frequency* CHF *
CHF proficiency* CHF frequency* Post MI *
Post MI proficiency* Post MI frequency* Pre / Post Cardiac Cath *
Pre / Post Cardiac Cath proficiency* Pre / Post Cardiac Cath frequency* Pre / Post Cardiac Surgery *
Pre / Post Cardiac Surgery proficiency* Pre / Post Cardiac Surgery frequency* Open Sternal Wound (Debridement) *
Open Sternal Wound (Debridement) proficiency* Open Sternal Wound (Debridement) frequency* Heart Transplant *
Heart Transplant proficiency* Heart Transplant frequency*
Medication Knowledge and Use of
Proficiency Rating
Frequency Rating
Atropine *
Atropine proficiency* Atropine frequency* Diuretics *
Diuretics proficiency* Diuretics frequency* Digoxin *
Digoxin proficiency* Digoxin frequency* Dopamine *
Dopamine proficiency* Dopamine frequency* Dobutrex *
Dobutrex proficiency* Dobutrex frequency* Heparin Drip (Precautions & Maintenance) *
Heparin Drip (Precautions & Maintenance) proficiency* Heparin Drip (Precautions & Maintenance) frequency* Inderal *
Inderal proficiency* Inderal frequency* Inocor *
Inocor proficiency* Inocor frequency* Isuprel *
Isuprel proficiency* Isuprel frequency* Lidocaine *
Lidocaine proficiency* Lidocaine frequency* Nipride *
Nipride proficiency* Nipride frequency* Nitroglycerin *
Nitroglycerin proficiency* Nitroglycerin frequency* Pronestyl *
Pronestyl proficiency* Pronestyl frequency* Morphine *
Morphine proficiency* Morphine frequency* Thrombolytic Agents *
Thrombolytic Agents proficiency* Thrombolytic Agents frequency* Magnesium Sulfate *
Magnesium Sulfate proficiency* Magnesium Sulfate frequency* Versed *
Versed proficiency* Versed frequency* Prep / Titration of Emergency Drugs *
Prep / Titration of Emergency Drugs proficiency* Prep / Titration of Emergency Drugs frequency*
Respiratory General Skills
Proficiency Rating
Frequency Rating
Establishing an Airway *
Establishing an Airway proficiency* Establishing an Airway frequency* Ambu-ing Techniques *
Ambu-ing Techniques proficiency* Ambu-ing Techniques frequency* Administration of O2 *
Administration of O2 proficiency* Administration of O2 frequency* Chest Tubes *
Chest Tubes proficiency* Chest Tubes frequency* Pulse Oximetry *
Pulse Oximetry proficiency* Pulse Oximetry frequency* Interpretation of ABG *
Interpretation of ABG proficiency* Interpretation of ABG frequency* Use of IPPB *
Use of IPPB proficiency* Use of IPPB frequency* Incentive Spirometer *
Incentive Spirometer proficiency* Incentive Spirometer frequency* Oral Suctioning *
Oral Suctioning proficiency* Oral Suctioning frequency* Nasotracheal Suctioning *
Nasotracheal Suctioning proficiency* Nasotracheal Suctioning frequency* ET Suctioning *
ET Suctioning proficiency* ET Suctioning frequency*
Respiratory Care of Patients with
Proficiency Rating
Frequency Rating
COPD *
COPD proficiency* COPD frequency* ARDS *
ARDS proficiency* ARDS frequency* Pre / Post Thoracic Surgery *
Pre / Post Thoracic Surgery proficiency* Pre / Post Thoracic Surgery frequency* Pulmonary embolism *
Pulmonary embolism proficiency* Pulmonary embolism frequency* Pulmonary Edema *
Pulmonary Edema proficiency* Pulmonary Edema frequency* Pneumothorax *
Pneumothorax proficiency* Pneumothorax frequency* Pneumonia *
Pneumonia proficiency* Pneumonia frequency* Inhalation Injuries *
Inhalation Injuries proficiency* Inhalation Injuries frequency* Emphysema *
Emphysema proficiency* Emphysema frequency* Asthma *
Asthma proficiency* Asthma frequency* Lung Transplant *
Lung Transplant proficiency* Lung Transplant frequency*
Medication Knowledge and Use of:
Proficiency Rating
Frequency Rating
Aminophylline *
Aminophylline proficiency* Aminophylline frequency* Corticosteroids *
Corticosteroids proficiency* Corticosteroids frequency* Bronchodilators *
Bronchodilators proficiency* Bronchodilators frequency*
Gastrointestinal General Skills
Proficiency Rating
Frequency Rating
NG Tube Insertion, Care and Maintenance *
NG Tube Insertion, Care and Maintenance proficiency* NG Tube Insertion, Care and Maintenance frequency* Gastrostomy Tube *
Gastrostomy Tube proficiency* Gastrostomy Tube frequency* Jejunostomy Tube *
Jejunostomy Tube proficiency* Jejunostomy Tube frequency* Enterostomal Care *
Enterostomal Care proficiency* Enterostomal Care frequency* Tube Feedings *
Tube Feedings proficiency* Tube Feedings frequency*
Gastrointestinal - Care of Patients with:
Proficiency Rating
Frequency Rating
Pancreatitis *
Pancreatitis proficiency* Pancreatitis frequency* G.I. Bleed *
G.I. Bleed proficiency* G.I. Bleed frequency* Esophageal Bleeding *
Esophageal Bleeding proficiency* Esophageal Bleeding frequency* Bowel Obstruction *
Bowel Obstruction proficiency* Bowel Obstruction frequency* Whipple Procedure *
Whipple Procedure proficiency* Whipple Procedure frequency* Liver Transplant *
Liver Transplant proficiency* Liver Transplant frequency* Paralytic Ileus *
Paralytic Ileus proficiency* Paralytic Ileus frequency* E.R.C.P. *
E.R.C.P. proficiency* E.R.C.P. frequency*
Medication Knowledge and Use of:
Proficiency Rating
Frequency Rating
Antiemetics *
Antiemetics proficiency* Antiemetics frequency* TPN / Hyperalimentation *
TPN / Hyperalimentation proficiency* TPN / Hyperalimentation frequency*
Genitourinary / Renal General Skills
Proficiency Rating
Frequency Rating
Peritoneal Dialysis *
Peritoneal Dialysis proficiency* Peritoneal Dialysis frequency* Hemodialysis *
Hemodialysis proficiency* Hemodialysis frequency* Foley / Straight Catheter Insertion *
Foley / Straight Catheter Insertion proficiency* Foley / Straight Catheter Insertion frequency* GU Irrigations *
GU Irrigations proficiency* GU Irrigations frequency* Nephrostomy Tube *
Nephrostomy Tube proficiency* Nephrostomy Tube frequency* Suprapubic Tube *
Suprapubic Tube proficiency* Suprapubic Tube frequency* Electrolyte Imbalance / Replacement *
Electrolyte Imbalance / Replacement proficiency* Electrolyte Imbalance / Replacement frequency*
Genitourinary / Renal - Care of Patients with:
Proficiency Rating
Frequency Rating
T.U.R.P. *
T.U.R.P. proficiency* T.U.R.P. frequency* Shunts and Fistulas *
Shunts and Fistulas proficiency* Shunts and Fistulas frequency* Nephrectomy *
Nephrectomy proficiency* Nephrectomy frequency* Renal Transplant *
Renal Transplant proficiency* Renal Transplant frequency* Renal Trauma *
Renal Trauma proficiency* Renal Trauma frequency* Chronic / Acute Renal Failure *
Chronic / Acute Renal Failure proficiency* Chronic / Acute Renal Failure frequency*
Gynecology General Skills
Proficiency Rating
Frequency Rating
GYN Exam Prep *
GYN Exam Prep proficiency* GYN Exam Prep frequency*
Gynecology - Care of Patients with:
Proficiency Rating
Frequency Rating
Ectopic Pregnancy / Ruptured Ectopic Pregnancy *
Ectopic Pregnancy / Ruptured Ectopic Pregnancy proficiency* Ectopic Pregnancy / Ruptured Ectopic Pregnancy frequency* Hysterectomy *
Hysterectomy proficiency* Hysterectomy frequency* Repair of Cystocele / Rectocele *
Repair of Cystocele / Rectocele proficiency* Repair of Cystocele / Rectocele frequency*
Orthopedic General Skills
Proficiency Rating
Frequency Rating
Assessment of C/M/S *
Assessment of C/M/S proficiency* Assessment of C/M/S frequency* K-Wises / Steinman Pins *
K-Wises / Steinman Pins proficiency* K-Wises / Steinman Pins frequency* Removal of Hardware *
Removal of Hardware proficiency* Removal of Hardware frequency*
Orthopedic - Care of Patients with:
Proficiency Rating
Frequency Rating
Total Joint Replacement *
Total Joint Replacement proficiency* Total Joint Replacement frequency* Spica Cast / Body Cast *
Spica Cast / Body Cast proficiency* Spica Cast / Body Cast frequency* Amputation *
Amputation proficiency* Amputation frequency* Traction *
Traction proficiency* Traction frequency* Ortho Trauma *
Ortho Trauma proficiency* Ortho Trauma frequency* Laminectomy *
Laminectomy proficiency* Laminectomy frequency*
Endocrine General Skills
Proficiency Rating
Frequency Rating
Diabetic Teaching *
Diabetic Teaching proficiency* Diabetic Teachingfrequency* Blood Glucose Monitoring *
Blood Glucose Monitoring proficiency* Blood Glucose Monitoring frequency* ENDOCRINE - CARE OF PATIENTS WITH:
Hyper / Hypoglycemia *
Hyper / Hypoglycemia proficiency* Hyper / Hypoglycemia frequency* THIS IS A SUB-HEADING
Insulin (IV, SQ) *
Insulin (IV, SQ) proficiency* Insulin (IV, SQ) frequency* D50 *
D50 proficiency* D50 frequency*
Phlebotomy / IV Therapy
Proficiency Rating
Frequency Rating
Peripheral IV Insertion, Care and Maintenance *
Peripheral IV Insertion, Care and Maintenance proficiency* Peripheral IV Insertion, Care and Maintenance frequency* Assisting with Insertion of Central Lines *
Assisting with Insertion of Central Lines proficiency* Assisting with Insertion of Central Lines frequency* Care and Maintenance of Central Lines *
Care and Maintenance of Central Lines proficiency* Care and Maintenance of Central Lines frequency* Assisting with Insertion of PICC Lines *
Assisting with Insertion of PICC Lines proficiency* Assisting with Insertion of PICC Lines frequency* Care and Maintenance of PICC Lines *
Care and Maintenance of PICC Lines proficiency* Care and Maintenance of PICC Lines frequency* Assist with IC Cutdown *
Assist with IC Cutdown proficiency* Assist with IC Cutdown frequency* Phlebitis *
Phlebitis proficiency* Phlebitis frequency*
Other
Proficiency Rating
Frequency Rating
Heparin Drip (Precautions and Maintenance) *
Heparin Drip (Precautions and Maintenance) proficiency* Heparin Drip (Precautions and Maintenance) frequency* Care of Oncology Patient *
Care of Oncology Patient proficiency* Care of Oncology Patient frequency* Chemotherapy Administration *
Chemotherapy Administration proficiency* Chemotherapy Administration frequency* Care of Patient with Burns *
Care of Patient with Burns proficiency* Care of Patient with Burns frequency* Care of Patient with HIV/AIDS *
Care of Patient with HIV/AIDS proficiency* Care of Patient with HIV/AIDS frequency* Hyperbaric Oxygenation *
Hyperbaric Oxygenation proficiency* Hyperbaric Oxygenation frequency* Suicide Precautions *
Suicide Precautions proficiency* Suicide Precautions frequency* Post Mortem Care *
Post Mortem Cares proficiency* Post Mortem Cares frequency*
Cardiac Monitors
Proficiency Rating
Frequency Rating
Hewlett - Packard *
Hewlett - Packard proficiency* Hewlett - Packard frequency* Spacelab *
Spacelab proficiency* Spacelab frequency* Siemens *
Siemens proficiency* Siemens frequency* Marquette *
Marquette proficiency* Marquette frequency* Mennen *
Mennen proficiency* Mennen frequency* Lifecare *
Lifecare proficiency* Lifecare frequency* Nihon - Koder *
Nihon - Koder proficiency* Nihon - Koder frequency* Other Cardiac Monitors Please List: *
Other Cardiac Monitors Please List: proficiency* Other Cardiac Monitors Please List: frequency*
Ventilators
Proficiency Rating
Frequency Rating
Bear *
Bear proficiency* Bear frequency* Bennett 7200 *
Bennett 7200 proficiency* Bennett 7200 frequency* CPAP *
CPAP proficiency* CPAP frequency* Emerson *
Emerson proficiency* Emerson frequency* Engstrom / Erica *
Engstrom / Erica proficiency* Engstrom / Erica frequency* EMV *
EMV proficiency* EMV frequency* MA-I *
MA-I proficiency* MA-I frequency* MA-II *
MA-II proficiency* MA-II frequency* Monihan *
Monihan proficiency* Monihan frequency* Ohio 560 *
Ohio 560 proficiency* Ohio 560 frequency* PEEP *
PEEP proficiency* PEEP frequency* Pressure Pre-Set *
Pressure Pre-Set proficiency* Pressure Pre-Set frequency* Servo *
Servo proficiency* Servo frequency* Siemens *
Siemens proficiency* Siemens frequency* Other Ventilators Monitors Please List: *
Other Ventilators Monitors Please List: proficiency* Other Ventilators Monitors Please List: frequency* Certify your information* I certify that I have provided true and accurate information about my skills and experience to the best of my ability
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