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.
| Processing | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Single instruments |
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| Endoscopes |
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| Repair |
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| Sets/ Trays |
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| Care of instruments |
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| Other (list): |
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| Decontamination | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Manual cleaning |
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| Washer sterilizer |
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| Soiled linen |
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| Disinfectants |
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| Sharps |
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| Disposable items |
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| Cleaning equipment |
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| Detergents |
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| Dress code |
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| Other (list): |
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| Steam Sterilization | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Chart recording |
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| Biological monitoring |
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| Time |
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| Testing/ Monitoring |
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| Other (list): |
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| Tests | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Test control |
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| Recording |
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| Other (list): |
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| Assembly andPreparation | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Wrapping materials |
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| Autoclave tape |
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| Dust covers |
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| Proper towel/ linen folding |
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| Proper labeling |
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| Expiration dates |
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| Packing for steam |
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| Heat sealing |
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| Instrument count sheets |
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| Placing instruments on trays |
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| Other (list): |
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| Age Specific Competencies | Rating Stars (Click) | 1 | 2 | 3 | 4 | ||
| Infant (Birth - 1 year) |
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| Preschooler (ages 2-5 years) |
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| Childhood (ages 6-12 years) |
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| Adolescents (ages 13-21 years) |
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| Young Adults (ages 22-39 years) |
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| Adults (ages 40-64 years) |
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| Older Adults (ages 65-79 years) |
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| Elderly (ages 80+ years) |
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