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Name
Phone Number
Email Address

Please rate your experience / frequency (within the last year) using the following scale
(check the appropriate boxes below):

1 - No Experience / Theory Only
2 - Limited Experience / Need Review
3 - Frequent Experience / May Need Some Review
4 - Experienced / Perform Well

1 - Observed Only / Never Done
2 - Rarely Done (<6 times/year)
3 - Occasionally Done (1 - 2 times/month)
4 - Frequently Done (daily or weekly)

	Experience				Frequency
CARDIAC	1	2	3	4	1	2	3	4
Interpretation of 12 Lead EKG
Interpretation of Arrhythmias
Defibrillation/Cardioversion
Assisting with Insertion of Central Lines
Pacemakers
External
Permanent
Temporary
Cardiac Arrest/CPR
Interpretation of Hemodynamic Monitoring
Art-Line (Transducer set-up, D/C)
Swan-Ganz (Transducer set-up, D/C)
Balloon Pump (IABP)
SVO2 Monitoring
Sheath Removal - Femoral
Automatic Internal Cardioverter Defibrillator
Care of Patient with
Aneurysm
Acute MI/Unstable Angina
CHF
Cardiogenic/Hypovolemic Shock
Pre/Post Cardiac Surgery
PTCA
Use & Administration of the Following
Atropine
Bretylol
Amiodarone
Digoxin
Dopamine
Dobutrex
Bicarbonate
Inocor
Diltiazem
Lidocaine
Neosynephrine/Nipride
Nitroglycerin
Pronestyl
Titrate Morphine
Verapamil
Esmolol
Metroprolol
Retavase
Epinephrine
Phenobarbital
Streptokinase
Valium
Versed
Alteplase
VASCULAR	1	2	3	4	1	2	3	4
Peripheral Pulses
Fluid Overload
Ultrasonic Doppler
Starting IV's
Assist with IV Cutdown
Subcutaneous Central Line
Hickman/Broviac/Groshong Catheters
Maintenance of Heparin Lock
TPN/Hyperalimentation
Air Occlusive Dressing
Knowledge of Normal Serum Lab Values
Administration of Blood & Blood Products
Infusion Pump
Peritoneal Dialysis
Hemodialysis
Heparin Drip (Precautions & Maintenance)
GASTROINTESTINAL	1	2	3	4	1	2	3	4
NG Tube Insertion
Gastrostomy Tube
Jejunostomy Tube
Enterostomal Care
Care of Patient with
Pancreatitis
GI Bleed
Esophageal Bleeding
Bowel Obstruction
Whipple Procedure
Liver Transplant
Paralytic Ileus
E.R.C.P.
GENITOURINARY/RENAL	1	2	3	4	1	2	3	4
Foley Catheter Insertion
GU Irrigations
Nephrostomy Tube
Suprapubic Tube
Electrolyte Imbalance/Replacement
Care of Patient with
T.U.R.P.
Shunts & Fistulas
Nephrectomy
Renal Transplant
Renal Failure
Renal Trauma

	Experience				Frequency
RESPIRATORY	1	2	3	4	1	2	3	4
Establishing an Airway
Ambuing Techniques
Chest Tubes (Emerson/Pleuravac)
Pulse Oximetry
Interpretation of ABG
Drawing ABG Blood Sample from Art-Line
Use of IPPB
Use of Pressure Support
Incentive Spirometer
Care of Patient with
COPD
ARDS
Pre/Post Thoracic Surgery
Pulmonary Embolism
Pulmonary Edema
Pneumonia
Inhalation Injuries
Use & Administration of the Following
Aminophylline
Corticosteroids
Bronkosol
Bentolin
Alupent
NEUROLOGY	1	2	3	4	1	2	3	4
Assessment of Neuro Signs
Glascow Coma Scale
Seizure Precautions
Assist with Lumbar Puncture
ICP Monitoring
Crutchfield Tongs
Halo Traction
Stryker Frame
Care of Patient with
CVA
Seizure Activity
Overdose
Neuro Injury/Trauma
Pre/Post Neuro Surgery
Cranial Hemorrhage
TRANSPLANTS	1	2	3	4	1	2	3	4
Heart
Lung
OTHER	0	1	2	3	0	1	2	3
Oncology
Chemotherapy
Isolation Techniques
Diabetic Teaching
Hyperbaric Oxygenation
Accucheck
AGE SPECIFIC COMPETENCY	1	2	3	4	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)
Young Adults (18 - 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the indivdual completing this form. I hereby authorize Texas Select Staffing to release this Skills Checklist to its client facilities for consideration of employment as a contractor at those facilities.