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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)

	CIRCULATE								SCRUB
	Experience				Frequency				Experience				Frequency
CARDIOVASCULAR	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Aortic Aneurysm
Aorto-Femoral Bypass, Graft Insertion
A-V Shunts
Cardiac Valve Replacement
Coronary Artery Bypass Graft
Endarterectomy Carotid/Femoral
External Temporary Pacemaker
Internal Pacemaker Insertion
Intra-Aortic Balloon Pump Catheter
Patent Ductus Repair
Pericardial Windows
Porta-Systemic Shunt
Repair of Septal Defects
Thrombectomy
Transplant Surgery
Vena Cava Ligation
ENDOSCOPY	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Bronchoscopy
Colonoscopy
Cystoscopy
Gastroscopy
E.N.T.	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Caldwell-Luc
Ethymoidectomy
Frontal Flap Sinus Procedure
Larynegectomy
Laryngoscopy
Mastoidectomy
Myringostomy
Nasal Polypectomy
Open Reduction Facial Features
Radical Neck
Stapedectomy
Tonsillectomy and Adenoidectomy
Tympanoplasty
EYE	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Canthotomy
Corneal Transplant
Correction of Ectropian/Entropian
Enucleation
Excision of Chalazion
Integrated Orbital Implants
Lacrimal Duct Probing
Refractive Keratoplasty
Repair of Retinal Detachment
Vitrectomy
GENERAL SURGERY	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Abdominal Perineal Resection
Adrenalectomy
Bowel Resection
Cholecystectomy
Colostomy/Ileostomy
Gastrectomy
Hemicolectomy
Hepatic Resection
Herniorrhaphy-Femoral/Inguinal
Hiatal Herniorrhaphy: Transabdominal
Pancreatectomy
Organ Procurement
Radical Mastectomy
Saphenous Vein Ligation and Stripping
Splenectomy
Thyroidectomy
Tracheostomy
Whipple Procedure
G.U. AND CYSTO	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Circumcision
Cystectomy
Cystoscopy/Cystostomy
Hypospadias Repair
Ileal Loop
Kidney Repair
Lithotripsy
Nephrectomy
Orchiectomy
Penile Implant
Prostatectomy
T.U.R.P./T.U.R.B.
Ureterolithotomy
Vasectomy
GYNECOLOGY	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Caesarean Section
Dilation and Curettage
Hysterectomy Abdominal
Hysterectomy Vaginal
Laser Surgery
Radium Insertion
Salpingo Oophorectomy
Shirodkar Procedure
Termination of Pregnancy
Tubal Ligation
Vaginal Reconstruction
Vaginectomy
LAPAROSCOPIC	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Appendectomy
Cholecystectomy
Colon Resection
Hernia Repair
NEUROSURGERY	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Anterior Cervical Fusion
Burr holes for Subdural Hemato ma
Craniotomy
Laminectomy
Meningocele Repair
Shunt Procedures VP/VA
ORTHOPEDIC	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Amputation Leg/Arm
Application of Halo Traction
Arthroscopy/Arthrotomy
Closed Pinning and Reduction of Extremities
External Compression Devices
Insertion of Finger Prosthesis
O.R.I.F. Shoulder, Hip, Humerus, etc.
Patellectomy
Repair of Dislocation
Spica Cast Application
Spinal Fusion Harrington Rods
Tendon Implants and Reanastomosis
Total Joint Replacement Knee, Hip, Shoulder
THORACIC	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Bronchoscopy
Chest Tube Set-Up Type
Hiatal Hernia
Lung/Wedge Resection
Pneumonectomy/Lobectomy
Sternal Splitting
Thoracotomy
PLASTICS	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Abdominoplasty/Abdominal Lipectomy
Augmentation Mammoplasty
Cleft Lip/Palate Repair
Dermabrasion
Digital Flexor Tendon Repair
Liposuction
Myelomeningocele Repair
Otoplasty
Rhinoplasty
Reduction of Facial Fracture
Scar Revision
Skin Meshing
Split Thickness Skin Grafting
AGE SPECIFIC COMPETENCY	1	2	3	4	1	2	3	4	1	2	3	4	1	2	3	4
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School age child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 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.