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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
TRAUMA	1	2	3	4	1	2	3	4
Air Transport of Trauma Patient
Care of Patient with
Major Trauma
Minor Trauma
M.A.S.T. Suit
BURNS	1	2	3	4	1	2	3	4
Care of Patient with
First Degree
Second Degree
Third Degree
Electrocution
Dressing Procedure
Hazardous Materials Exposure
Radiation Exposure
RESPIRATORY	1	2	3	4	1	2	3	4
Care of Patient with
Pulmonary Edema
C.O.P.D.
Pneumothorax
Assisting with Intubation
Assisting with Extubation
T-Piece
Obtaining Arterial Blood Gases
From Radial Artery
From Femoral Artery
From Arterial Line
Setting Up of Arterial Line
Ventilator
O2 Mask
O2 Cannula
Venturi Mask
Ambu Bags
O2 Cylinders
Nebulizer Set-Up
Oropharyngeal Suction
Nasotracheal Suction
Endotracheal Suction
Assisting with Chest Tube Insertion
Use of Pleuravac Drainage System
Use of Emerson Drainage System
GASTROINTESTINAL	1	2	3	4	1	2	3	4
Care of Patient with
G.I. Bleed
Abdominal Wounds
G.I. Tubes
Acute Abdominal Disorders
Insertion of Nasogastric Tube
Gastric Lavage
RENAL	1	2	3	4	1	2	3	4
Care of Patient with
Acute Renal Failure
Chronic Renal Failure
Peritoneal Dialysis
ORTHOPEDIC	1	2	3	4	1	2	3	4
Care of Patient with
Set-up for Cast Application
Checking C.M.S.
Set-up for OCL Splinting
Set-up for Insertion of Steinman Pin/K-Wires Insertion
Assist with Closed Fracture/Dislocation Reduction
Sedation Monitoring
Application of Orthopedic Appliances
EENT DISORDERS	1	2	3	4	1	2	3	4
Care of Patient with
Set-up for Fluorescein/Woods Lamp Exam
Use of Morgan Lens Irrigation
Ear Irrigations
Eye Irrigations
Eye Patch Application
Nasal Packing
Remove Contact Lens
Visual Acuity
LACERATIONS	1	2	3	4	1	2	3	4
Care of Patient with
Setting up Suture Tray
Assist with Sutures
Assist with Staples
Suture Removal
Staple Removal
Steri Strips
PEDIATRIC	1	2	3	4	1	2	3	4
Calculating Emergency Medication Dosages
Knowledge of Normal Serum Lab Values
Care of Patient with
Pediatric Arrest/Resuscitation
Epiglottitis
Overdose/Poison Ingestion
Near Drowning
Child Abuse
MISCELLANEOUS INSTRUMENTS/TRAYS	1	2	3	4	1	2	3	4
Pelvic Tray
Cut Down Tray
Procto Tray
CVP Tray
Trach Tray
Culdocentesis Tray
Thoracentesis Tray

	Experience				Frequency
OBSTETRICS/GYNECOLOGY	1	2	3	4	1	2	3	4
Care of Patient with
Spontaneous Abortion
Hemorrhage
Placenta Previa
Abruptio Placenta
Pre-eclampsia/Eclampsia
Emergency Delivery
Communicable Diseases
PSYCHIATRIC	1	2	3	4	1	2	3	4
Crisis Intervention
Upholding Patient's Rights
Care of
Suicidal Patient
Patient with Overdose
Patient in Restraints
NEUROLOGICAL	1	2	3	4	1	2	3	4
Neuro Assessment
Monitoring Neuro Signs
Use of Glascow Coma Scale
Acute Head Injury
Acute T.I.A./C.V.A.
Acute Spinal Cord Injury
Seizure Precautions
Observing for Increased Intracranial Pressure
Application of Orthopedic Appliances
Transport of Patient with Spinal Cord Injuries
Assist with Lumbar Puncture
Knowledge & Use of
Dilantin
Phenobarbital
Decadron
Mannitol
Solu-Medrol
CARDIOVASCULAR	1	2	3	4	1	2	3	4
Care of Patient with
Acute MI, CHF, Angina
Abdominal Aortic Aneurysm
Cardiac Monitoring
Recognizing Arrhythmias
Obtaining 12 Lead EKG's
Cardiopulmonary Arrest
Cardioversion
Defibrillation
Open Chest Heart Massage
Assist with Insertion of
Permanent Pacemakers
Temporary Pacemakers
Trans-thoracic Pacemaker
Pervenous Pacemaker
Set-up & Use of CVP
Interpretation of CVP Readings
Interpretation of Swan-Ganz Readings
Thrombolytic Therapy
Anaphylactic Shock
Cardiogenic Shock
Septic Shock
Hypovolemic Shock
Administration of Blood & Blood Products
Preparation/Calculation of the Following Drugs
Lidocaine
Bretylium
Nipride
Dopamine
Isuprel
Digitalis
Sodium Bicarbonate
Atropine
Epinephrine
Dobutrex
Tridil/Nitroglycerine
SEXUAL ASSAULT/CHILD ABUSE	1	2	3	4	1	2	3	4
Sexual Assault Kit
Reporting Procedures for Acts of Violence
ENVIRONMENTAL	1	2	3	4	1	2	3	4
Care of Patient with
Hypothermia
Heat Stroke
Heat Exhaustion
Snake Bite
Administration of Antivenim
Animal Bite
Poison Index
ADDITIONAL E.R. SKILLS	1	2	3	4	1	2	3	4
Isolation Procedures
Triage Procedures
Care of Patient with AIDS
Lab Values
Procedure for Patient Signing AMA
Consent for Treatment of Minor
Disaster Protocols
Heparin/Saline Lock
Starting IV's
Adult
Pediatric
Universal Precautions
Assist with Peritoneal Lavage
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.