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: |
 |
||||||
| Minor Trauma |
|
||||||
| Major Trauma |
|
||||||
| MAST Suit |
|
||||||
| BURNS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Care of Patient with: |
|
||||||
| First Degree |
|
||||||
| Second Degree |
|
||||||
| Third Degree |
|
||||||
| Electrocution |
|
||||||
| Hazardous Materials Exposure |
|
||||||
| LACERATIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Care of Patient with: |
|
||||||
| Assessment |
|
||||||
| Cleansing |
|
||||||
| Steri-Strips |
|
||||||
| Dressing |
|
||||||
| SPRAIN/STRAIN | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Assessment |
|
||||||
| Carpal Tunnel |
|
||||||
| Tendonitis |
|
||||||
| Epicondylitis |
|
||||||
| PHYSICALS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Safety |
|
||||||
| Return to Work |
|
||||||
| Respirator |
|
||||||
| Vital Signs |
|
||||||
| Height/Weight |
|
||||||
| Blood Draw |
|
||||||
| Medical Referral Form |
|
||||||
| Medical Certification Form |
|
||||||
| Medical History Questionnaire |
|
||||||
| Potassium Iodine Assessment |
|
||||||
| RESTRICTIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Temporary Restrictions |
|
||||||
| Permanent Restrictions |
|
||||||
| Pulmonary Function |
|
||||||
| Audiometry |
|
||||||
| Vision Testing |
|
||||||
| X-ray |
|
||||||
| Urine Testing |
|
||||||
| Drug Testing |
|
||||||
| Breathalyzer |
|
||||||
| IMMUNIZATIONS | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Havrix (Hepatitis A) |
|
||||||
| Influenza Vaccine |
|
||||||
| Meningitis Vaccine |
|
||||||
| Tetanus & Diphtheria |
|
||||||
| Oral Typhoid Vaccine |
|
||||||
| Polio Vaccine |
|
||||||
| Hepatitis B Vaccine |
|
||||||
| Japanese Encephalitis B |
|
||||||
| Rabies Vaccine |
|
||||||
| Typhim (Injectable Type) |
|
||||||
| Yellow Fever Vaccine |
|
||||||
| Age Specific Criteria | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Newborn/Neonate (birth-30 days) |
|
||||||
| Infant (30 days - 1 year) |
|
||||||
| Toddler (1-3 years) |
|
||||||
| Preschooler (3-5 years) |
|
||||||
| School Age Children (5-12 years) |
|
||||||
| Adolescents (12-18 years) |
|
||||||
| Adolescents (12-18 years) |
|
||||||
| Young Adults (18-39 years) |
|
||||||
| Middle Adults (39-64 years) |
|
||||||
| Older Adults (64+) |
|
||||||