Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
TRAUMA | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Care of Patient with: |
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Minor Trauma |
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Major Trauma |
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MAST Suit |
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BURNS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Care of Patient with: |
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First Degree |
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Second Degree |
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Third Degree |
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Electrocution |
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Hazardous Materials Exposure |
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LACERATIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Care of Patient with: |
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Assessment |
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Cleansing |
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Steri-Strips |
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Dressing |
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SPRAIN/STRAIN | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Assessment |
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Carpal Tunnel |
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Tendonitis |
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Epicondylitis |
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PHYSICALS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Safety |
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Return to Work |
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Respirator |
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Vital Signs |
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Height/Weight |
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Blood Draw |
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Medical Referral Form |
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Medical Certification Form |
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Medical History Questionnaire |
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Potassium Iodine Assessment |
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RESTRICTIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Temporary Restrictions |
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Permanent Restrictions |
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Pulmonary Function |
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Audiometry |
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Vision Testing |
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X-ray |
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Urine Testing |
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Drug Testing |
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Breathalyzer |
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IMMUNIZATIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Havrix (Hepatitis A) |
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Influenza Vaccine |
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Meningitis Vaccine |
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Tetanus & Diphtheria |
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Oral Typhoid Vaccine |
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Polio Vaccine |
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Hepatitis B Vaccine |
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Japanese Encephalitis B |
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Rabies Vaccine |
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Typhim (Injectable Type) |
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Yellow Fever Vaccine |
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Age Specific Criteria | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
Newborn/Neonate (birth-30 days) |
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Infant (30 days - 1 year) |
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Toddler (1-3 years) |
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Preschooler (3-5 years) |
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School Age Children (5-12 years) |
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Adolescents (12-18 years) |
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Adolescents (12-18 years) |
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Young Adults (18-39 years) |
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Middle Adults (39-64 years) |
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Older Adults (64+) |
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