Anesthesia Tech

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Name*

First Last

Phone*

Email*

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 Knowledge

Proficiency Rating

Frequency Rating

Proper identification of patient using at least two identifiers *

Proper identification of patient using at least two identifiers proficiency*

Proper identification of patient using at least two identifiers frequency*

Proper identification/labeling of all lab specimens/results *

Proper identification/labeling of all lab specimens/results proficiency*

Proper identification/labeling of all lab specimens/results frequency*

Participate in the pre-procedural time-out process *

Participate in the pre-procedural time-out process proficiency*

Participate in the pre-procedural time-out process frequency*

Demonstrate appropriate application of all monitoring devices *

Demonstrate appropriate application of all monitoring devices proficiency*

Demonstrate appropriate application of all monitoring devices frequency*

Implement guidelines, policies and safety requirements according to regulatory and standard setting agencies *

Implement guidelines, policies and safety requirements according to regulatory and standard setting agencies proficiency*

Implement guidelines, policies and safety requirements according to regulatory and standard setting agencies frequency*

Perform technical duties in complex clinical situations *

Perform technical duties in complex clinical situations proficiency*

Perform technical duties in complex clinical situations frequency*

Use of medical terminology as it relates to anesthesia patient care *

Use of medical terminology as it relates to anesthesia patient care proficiency*

Use of medical terminology as it relates to anesthesia patient care frequency*

Coordinate the daily routine of the technical anesthesia staff *

Coordinate the daily routine of the technical anesthesia staff proficiency*

Coordinate the daily routine of the technical anesthesia staff frequency*

Practice basic patient care related to anesthesia *

Practice basic patient care related to anesthesia proficiency*

Practice basic patient care related to anesthesia frequency*

Recognize scope of practice and limitations as a Certified Anesthesia Technician *

Recognize scope of practice and limitations as a Certified Anesthesia Technician proficiency*

Recognize scope of practice and limitations as a Certified Anesthesia Technician frequency*

Prioritize tasks related to role and function *

Prioritize tasks related to role and function proficiency*

Prioritize tasks related to role and function frequency*

Delegate responsibilities to other members of the anesthesia team *

Delegate responsibilities to other members of the anesthesia team proficiency*

Delegate responsibilities to other members of the anesthesia team frequency*

Adhere to professional standards to uphold patient rights and confidentiality *

Adhere to professional standards to uphold patient rights and confidentiality proficiency*

Adhere to professional standards to uphold patient rights and confidentiality frequency*

Perform administrative duties such as evaluations and program development *

Perform administrative duties such as evaluations and program development proficiency*

Perform administrative duties such as evaluations and program development frequency*

Participate in continuing education development for the Certified Anesthesia Technician *

Participate in continuing education development for the Certified Anesthesia Technician proficiency*

Participate in continuing education development for the Certified Anesthesia Technician frequency*

Implement safety procedures and principles related to fire safety and infection control *

Implement safety procedures and principles related to fire safety and infection control proficiency*

Implement safety procedures and principles related to fire safety and infection control frequency*

Provide for safe environment related to electrical equipment in the OR *

Provide for safe environment related to electrical equipment in the OR proficiency*

Provide for safe environment related to electrical equipment in the OR frequency*

Locate supplies in Anesthesia workroom *

Locate supplies in Anesthesia workroom proficiency*

Locate supplies in Anesthesia workroom frequency*

Identify Anesthesia Specialty carts storage location *

Identify Anesthesia Specialty carts storage location proficiency*

Identify Anesthesia Specialty carts storage location frequency*

Perform inventory of equipment and supplies *

Perform inventory of equipment and supplies proficiency*

Perform inventory of equipment and supplies frequency*

Setup anesthesia supplies and equipment for the first case *

Setup anesthesia supplies and equipment for the first case proficiency*

Setup anesthesia supplies and equipment for the first case frequency*

Room turnover Procedures *

Room turnover Procedures proficiency*

Room turnover Procedures frequency*

Troubleshoot all anesthesia delivery systems, monitors, and ancillary devices *

Troubleshoot all anesthesia delivery systems, monitors, and ancillary devices proficiency*

Troubleshoot all anesthesia delivery systems, monitors, and ancillary devices frequency*

Participate in Quality Assurance related to providing anesthesia care *

Participate in Quality Assurance related to providing anesthesia care proficiency*

Participate in Quality Assurance related to providing anesthesia care frequency*

Maintain quality control records for the anesthesia department *

Maintain quality control records for the anesthesia department proficiency*

Maintain quality control records for the anesthesia department frequency*

Participate in equipment training programs regarding anesthesia equipment usage and troubleshooting *

Participate in equipment training programs regarding anesthesia equipment usage and troubleshooting proficiency*

Participate in equipment training programs regarding anesthesia equipment usage and troubleshooting frequency*

Anatomy & Physiological Components

Proficiency Rating

Frequency Rating

Recognize normal physiologic and laboratory values associated with the administration of anesthesia *

Recognize normal physiologic and laboratory values associated with the administration of anesthesia proficiency*

Recognize normal physiologic and laboratory values associated with the administration of anesthesia frequency*

Recognize correlation between physiology and anesthesia care *

Recognize correlation between physiology and anesthesia care proficiency*

Recognize correlation between physiology and anesthesia care frequency*

Recognize function of and understand basic anatomy related to the musculoskeletal system *

Recognize function of and understand basic anatomy related to the musculoskeletal system proficiency*

Recognize function of and understand basic anatomy related to the musculoskeletal system frequency*

Recognize function of and understand basic anatomy related to the nervous system *

Recognize function of and understand basic anatomy related to the nervous system proficiency*

Recognize function of and understand basic anatomy related to the nervous system frequency*

Recognize function of and understand basic anatomy related to the respiratory system *

Recognize function of and understand basic anatomy related to the respiratory system proficiency*

Recognize function of and understand basic anatomy related to the respiratory system frequency*

Recognize function of and understand basic Anatomy related to the vascular system *

Recognize function of and understand basic Anatomy related to the vascular system proficiency*

Recognize function of and understand basic Anatomy related to the vascular system frequency*

Equipment - Airway Management:

Proficiency Rating

Frequency Rating

Emergency intubation kits *

Emergency intubation kits proficiency*

Emergency intubation kits frequency*

Fiberoptic bronchoscopes *

Fiberoptic bronchoscopes proficiency*

Fiberoptic bronchoscopes frequency*

Light wand *

Light wand proficiency*

Light wand frequency*

Emergency cricothyrotomy catheter sets *

Emergency cricothyrotomy catheter sets proficiency*

Emergency cricothyrotomy catheter sets frequency*

COPA *

COPA proficiency*

COPA frequency*

Equipment - Types of Airways:

Proficiency Rating

Frequency Rating

Nasal *

Nasal proficiency*

Nasal frequency*

Oral *

Oral proficiency*

Oral frequency*

Cuffed Endotracheal tubes *

Cuffed Endotracheal tubes proficiency*

Cuffed Endotracheal tubes frequency*

Uncuffed Endotracheal tubes *

Uncuffed Endotracheal tubes proficiency*

Uncuffed Endotracheal tubes frequency*

Double lumen endobronchial tube *

Double lumen endobronchial tube proficiency*

Double lumen endobronchial tube frequency*

Flexibend Endotracheal tubes *

Flexibend Endotracheal tubes proficiency*

Flexibend Endotracheal tubes frequency*

RAE (nasal and oral) Endotracheal tubes *

RAE (nasal and oral) Endotracheal tubes proficiency*

RAE (nasal and oral) Endotracheal tubes frequency*

Red rubber Endotracheal tubes *

Red rubber Endotracheal tubes proficiency*

Red rubber Endotracheal tubes frequency*

Reinforced Endotracheal tubes *

Reinforced Endotracheal tubes proficiency*

Reinforced Endotracheal tubes frequency*

Laser tube Endotracheal tubes *

Laser tube Endotracheal tubes proficiency*

Laser tube Endotracheal tubes frequency*

LMA *

LMA proficiency*

LMA frequency*

Equipment - Identification of:

Proficiency Rating

Frequency Rating

Emergency infusion device *

Emergency infusion device proficiency*

Emergency infusion device frequency*

Internal jugular kits *

Internal jugular kits proficiency*

Internal jugular kits frequency*

IV catheters *

IV catheters proficiency*

IV catheters frequency*

IV fluid/blood administration sets *

IV fluid/blood administration sets proficiency*

IV fluid/blood administration sets frequency*

Percutaneous introducer *

Percutaneous introducer proficiency*

Percutaneous introducer frequency*

Radial artery catheters *

Radial artery catheters proficiency*

Radial artery catheters frequency*

Swan-Ganz *

Swan-Ganz proficiency*

Swan-Ganz frequency*

Vascular access kits *

Vascular access kits proficiency*

Vascular access kits frequency*

Equipment - Set Up:

Proficiency Rating

Frequency Rating

Hotline fluid warmer w/label *

Hotline fluid warmer w/label proficiency*

Hotline fluid warmer w/label frequency*

Level 2 Rapid Infuser *

Level 2 Rapid Infuser proficiency*

Level 2 Rapid Infuser frequency*

Assemble, disassemble and clean Intubation Scope *

Assemble, disassemble and clean Intubation Scope proficiency*

Assemble, disassemble and clean Intubation Scope frequency*

BIS monitor(Bispectral Index Monitor) *

BIS monitor(Bispectral Index Monitor) proficiency*

BIS monitor(Bispectral Index Monitor) frequency*

Breathing circuits and masks *

Breathing circuits and masks proficiency*

Breathing circuits and masks frequency*

Breathing circuit leak test *

Breathing circuit leak test proficiency*

Breathing circuit leak test frequency*

Disassemble/reassemble absorber for cleaning, disinfecting and sterilizing as appropriate *

Disassemble/reassemble absorber for cleaning, disinfecting and sterilizing as appropriate proficiency*

Disassemble/reassemble absorber for cleaning, disinfecting and sterilizing as appropriate frequency*

ET tube *

ET tube proficiency*

ET tube frequency*

Glucometer *

Glucometer proficiency*

Glucometer frequency*

Laryngoscope blades *

Laryngoscope blades proficiency*

Laryngoscope blades frequency*

O2 transport and emergency ventilation systems *

O2 transport and emergency ventilation systems proficiency*

O2 transport and emergency ventilation systems frequency*

Set up heater/humidifier circuit on anesthesia machine *

Set up heater/humidifier circuit on anesthesia machine proficiency*

Set up heater/humidifier circuit on anesthesia machine frequency*

Self-inflating resuscitation bag *

Self-inflating resuscitation bag proficiency*

Self-inflating resuscitation bag frequency*

Tracheal intubation *

Tracheal intubation proficiency*

Tracheal intubation frequency*

Trans-tracheal jet ventilation device *

Lithotripsy proficiency*

Trans-tracheal jet ventilation device frequency*

Confirm the presence of suction apparatus/equipment *

Confirm the presence of suction apparatus/equipment proficiency*

Confirm the presence of suction apparatus/equipment frequency*

Zero & Calibrate all equipment and devices, as appropriate *

Zero & Calibrate all equipment and devices, as appropriate proficiency*

Zero & Calibrate all equipment and devices, as appropriate frequency*

Equipment - Set-Up IV and Pressure Lines:

Proficiency Rating

Frequency Rating

Arterial *

Arterial proficiency*

Arterial frequency*

Central venous *

Central venous proficiency*

Central venous frequency*

Intracranial pressure (ICP) *

Intracranial pressure (ICP) proficiency*

Intracranial pressure (ICP) frequency*

Pulmonary arterial line *

Pulmonary arterial line proficiency*

Pulmonary arterial line frequency*

Equipment - Set-Up and/ or Calibrate:

Proficiency Rating

Frequency Rating

Auto-transfusion reservoirs *

Auto-transfusion reservoirs proficiency*

Auto-transfusion reservoirs frequency*

Blood pressure monitors *

Blood pressure monitors proficiency*

Blood pressure monitors frequency*

Blood warmers *

Blood warmers proficiency*

Blood warmers frequency*

Capnography equipment *

Capnography equipment proficiency*

Capnography equipment frequency*

Doppler equipment *

Doppler equipment proficiency*

Doppler equipment frequency*

ECG *

ECG proficiency*

ECG frequency*

Infusion pumps *

Infusion pumps proficiency*

Infusion pumps frequency*

Non-invasive monitoring *

Non-invasive monitoring proficiency*

Non-invasive monitoring frequency*

Intra-operative EEG equipment *

Intra-operative EEG equipment proficiency*

Intra-operative EEG equipment frequency*

Invasive lines *

Invasive lines proficiency*

Invasive lines frequency*

Precordial stethoscope *

Precordial stethoscope proficiency*

Precordial stethoscope frequency*

Pressure transducers *

Pressure transducers proficiency*

Pressure transducers frequency*

Pulse oximeter *

Pulse oximeter proficiency*

Pulse oximeter frequency*

SVO2 *

SVO2 proficiency*

SVO2 frequency*

Transport monitor *

Transport monitor proficiency*

Transport monitor frequency*

Temperature monitor *

Temperature monitor proficiency*

Temperature monitor frequency*

Transesophageal echocardiography (TEE) *

Transesophageal echocardiography (TEE) proficiency*

Transesophageal echocardiography (TEE) frequency*

Equipment - Perform Inventory of:

Proficiency Rating

Frequency Rating

Equipment - Perform Inventory of: *

Equipment - Perform Inventory of: proficiency*

Equipment - Perform Inventory of: frequency*

Difficult Airway Cart *

Difficult Airway Cart proficiency*

Difficult Airway Cart frequency*

Malignant Hyperthermia Cart *

Malignant Hyperthermia Cart proficiency*

Malignant Hyperthermia Cart frequency*

Pediatric Anesthesia Cart *

Pediatric Anesthesia Cart proficiency*

Pediatric Anesthesia Cart frequency*

Lining Carts (annex) *

Lining Carts (annex) proficiency*

Lining Carts (annex) frequency*

Heart/ AAA Anesthesia Cart *

Heart/ AAA Anesthesia Cart proficiency*

Heart/ AAA Anesthesia Cart frequency*

Exchange of Anesthesia Care Process Flow *

Exchange of Anesthesia Care Process Flow proficiency*

Exchange of Anesthesia Care Process Flow frequency*

Infection Control

Proficiency Rating

Frequency Rating

Dispose of contaminated materials in accordance with facility protocols *

Dispose of contaminated materials in accordance with facility protocols proficiency*

Dispose of contaminated materials in accordance with facility protocols frequency*

Clean, sterilize and perform high-level disinfecting of all reusable items (excluding disassembly and reassembly) *

Clean, sterilize and perform high-level disinfecting of all reusable items (excluding disassembly and reassembly) proficiency*

Clean, sterilize and perform high-level disinfecting of all reusable items (excluding disassembly and reassembly) frequency*

Arterial line insertion *

Arterial line insertion proficiency*

Arterial line insertion frequency*

Central line insertion *

Central line insertion proficiency*

Central line insertion frequency*

Swan-Ganz line insertion *

Swan-Ganz line insertion proficiency*

Swan-Ganz line insertion frequency*

Cleaning of equipment *

Cleaning of equipment proficiency*

Cleaning of equipment frequency*

High-level disinfecting of equipment *

High-level disinfecting of equipment proficiency*

High-level disinfecting of equipment frequency*

Sterilization of equipment *

Sterilization of equipment proficiency*

Sterilization of equipment frequency*

Perform sterilization w/ Ethylene oxide *

Perform sterilization w/ Ethylene oxide proficiency*

Perform sterilization w/ Ethylene oxide frequency*

Perform sterilization w/ Gamma radiation *

Perform sterilization w/ Gamma radiation proficiency*

Perform sterilization w/ Gamma radiation frequency*

Perform sterilization w/ Glutaraldehyde *

Perform sterilization w/ Glutaraldehyde proficiency*

Perform sterilization w/ Glutaraldehyde frequency*

Perform sterilization w/ Steam *

Perform sterilization w/ Steam proficiency*

Perform sterilization w/ Steam frequency*

Procedures

Proficiency Rating

Frequency Rating

Assist Anesthesia Provider: Patient Assessments *

Assist Anesthesia Provider: Patient Assessments proficiency*

Assist Anesthesia Provider: Patient Assessments frequency*

Assist Anesthesia Provider: Patient Evaluations *

Assist Anesthesia Provider: Patient Evaluations proficiency*

Assist Anesthesia Provider: Patient Evaluations frequency*

Assist Anesthesia Provider: Patient Transport *

Assist Anesthesia Provider: Patient Transport proficiency*

Assist Anesthesia Provider: Patient Transport frequency*

Assist Anesthesia Provider: Patient Positioning *

Assist Anesthesia Provider: Patient Positioning proficiency*

Assist Anesthesia Provider: Patient Positioning frequency*

Assist Anesthesia Provider: Insertion of intravenous and other invasive lines *

Assist Anesthesia Provider: Insertion of intravenous and other invasive lines proficiency*

Assist Anesthesia Provider: Insertion of intravenous and other invasive lines frequency*

Assist Anesthesia Provider: Airway management *

Assist Anesthesia Provider: Airway management proficiency*

Assist Anesthesia Provider: Airway management frequency*

Assist Anesthesia Provider: Obtain blood samples from indwelling line for laboratory tests under direct supervision *

Assist Anesthesia Provider: Obtain blood samples from indwelling line for laboratory tests under direct supervision proficiency*

Assist Anesthesia Provider: Obtain blood samples from indwelling line for laboratory tests under direct supervision frequency*

Assist Anesthesia Provider: Establishment of vascular access *

Assist Anesthesia Provider: Establishment of vascular access proficiency*

Assist Anesthesia Provider: Establishment of vascular access frequency*

Assist Anesthesia Provider: Identification and check-out of blood products *

Assist Anesthesia Provider: Identification and check-out of blood products proficiency*

Assist Anesthesia Provider: Identification and check-out of blood products frequency*

Intra-Operative Complications: Cardiac Arrest *

Intra-Operative Complications: Cardiac Arrest proficiency*

Intra-Operative Complications: Cardiac Arrestfrequency*

Intra-Operative Complications: Malignant Hyperthermia *

Intra-Operative Complications: Malignant Hyperthermia proficiency*

Intra-Operative Complications: Malignant Hyperthermia frequency*

Intra-Operative Complications: Identify reportable and nonreportable events regarding devices *

Intra-Operative Complications: Identify reportable and nonreportable events regarding devices proficiency*

Intra-Operative Complications: Identify reportable and nonreportable events regarding devices frequency*

Intra-Operative Complications: Identify reportable and nonreportable events regarding patients and staff *

Intra-Operative Complications: Identify reportable and nonreportable events regarding patients and staff proficiency*

Intra-Operative Complications: Identify reportable and nonreportable events regarding patients and staff frequency*

Pharmacology

Proficiency Rating

Frequency Rating

Identify and set-up pre-mixed pharmaceutical solutions and infusion pumps *

Identify and set-up pre-mixed pharmaceutical solutions and infusion pumps proficiency*

Identify and set-up pre-mixed pharmaceutical solutions and infusion pumps frequency*

Identify pharmaceuticals in the supply cart *

Identify pharmaceuticals in the supply cart proficiency*

Identify pharmaceuticals in the supply cart frequency*

Types of Anesthesia: General *

Types of Anesthesia: General proficiency*

Types of Anesthesia: General frequency*

Types of Anesthesia: Regional *

Types of Anesthesia: Regional proficiency*

Types of Anesthesia: Regional frequency*

Types of Anesthesia: Monitored *

Types of Anesthesia: Monitored proficiency*

Types of Anesthesia: Monitored frequency*

Anesthesia Machine & Gas Delivery

Proficiency Rating

Frequency Rating

Perform attachment of PEEP and CPAP devices *

Perform attachment of PEEP and CPAP devices proficiency*

Perform attachment of PEEP and CPAP devices frequency*

Perform analysis of anesthesia machines prior to induction following FDA pre-use guidelines *

Perform analysis of anesthesia machines prior to induction following FDA pre-use guidelines proficiency*

Perform analysis of anesthesia machines prior to induction following FDA pre-use guidelines frequency*

Evaluate for depletion of the sodalime in the CO2 absorbers after each use *

Evaluate for depletion of the sodalime in the CO2 absorbers after each use proficiency*

Evaluate for depletion of the sodalime in the CO2 absorbers after each use frequency*

Replace sodalime CO2 absorbers after each use *

Replace sodalime CO2 absorbers after each use proficiency*

Replace sodalime CO2 absorbers after each use frequency*

Identify and properly handle respiratory and anesthetic gas cylinders *

Identify and properly handle respiratory and anesthetic gas cylinders proficiency*

Identify and properly handle respiratory and anesthetic gas cylinders frequency*

Identify and properly handle volatile anesthetic agents *

Identify and properly handle volatile anesthetic agents proficiency*

Identify and properly handle volatile anesthetic agents frequency*

Implement manufacturer’s specifications regarding maintenance, routine servicing, and calibration of anesthesia equipment *

Implement manufacturer’s specifications regarding maintenance, routine servicing, and calibration of anesthesia equipment proficiency*

Implement manufacturer’s specifications regarding maintenance, routine servicing, and calibration of anesthesia equipment frequency*

Dispose of exhausted CO2 absorbent according to facility protocol *

Dispose of exhausted CO2 absorbent according to facility protocol proficiency*

Dispose of exhausted CO2 absorbent according to facility protocol frequency*

Clinical Settings

Proficiency Rating

Frequency Rating

Operating room (OR) *

Operating room (OR) proficiency*

Operating room (OR) frequency*

Obstetrics suite (OB) *

Obstetrics suite (OB) proficiency*

Obstetrics suite (OB) frequency*

Interventional and/or diagnostic radiology *

Interventional and/or diagnostic radiology proficiency*

Interventional and/or diagnostic radiology frequency*

Post anesthesia care unit (PACU) *

Post anesthesia care unit (PACU) proficiency*

Post anesthesia care unit (PACU) frequency*

Cath Lab *

Cath Lab proficiency*

Cath Lab frequency*

Emergency room (ER) *

Emergency room (ER) proficiency*

Emergency room (ER) frequency*

GI/Endoscopy *

GI/Endoscopy proficiency*

GI/Endoscopy frequency*

Dental suites *

Dental suites proficiency*

Dental suites frequency*

Ambulatory surgery suites *

Ambulatory surgery suites proficiency*

Ambulatory surgery suites 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

Signature*

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Date*

Skills/Competences

Proficiency

Frequency

ANESTHESIA TECH

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