OR – Circulate Skills Checklist Name* First Last Email* Phone*Proficiency: 1 = Minimal Experience 2 = Limited Experience 3 = Competent 4 = Highly SkilledCardiovascularAortic Aneurysm* 1 2 3 4 Aorto-Femoral Bypass, Graft Insertion* 1 2 3 4 A-V Shunts* 1 2 3 4 Cardiac Valve Replacement* 1 2 3 4 Coronary Artery Bypass Graft* 1 2 3 4 Endarterectomy Carotid / Femoral* 1 2 3 4 External Temporary Pacemaker* 1 2 3 4 Internal Pacemaker Insertion* 1 2 3 4 Intra-Aortic Balloon Pump Catheter* 1 2 3 4 Patent Ductus Repair* 1 2 3 4 Pericardial Windows* 1 2 3 4 Porta-Systemic Shunt* 1 2 3 4 Repair of Septal Defects* 1 2 3 4 Thrombectomy* 1 2 3 4 Transplant Surgery* 1 2 3 4 Vena Cava Ligation* 1 2 3 4 EndoscopyBronchoscopy* 1 2 3 4 Colonoscopy* 1 2 3 4 Cystoscopy* 1 2 3 4 Gastroscopy* 1 2 3 4 E.N.T.Caldwell-Luc* 1 2 3 4 Ethmoidectomy* 1 2 3 4 Frontal Flap Sinus Procedure* 1 2 3 4 Laryngectomy* 1 2 3 4 Laryngoscopy* 1 2 3 4 Mastoidectomy* 1 2 3 4 Nasal Polypectomy* 1 2 3 4 Open Reduction Facial Features* 1 2 3 4 Radical Neck* 1 2 3 4 Stapedectomy* 1 2 3 4 Tonsillectomy and Adenoidectomy* 1 2 3 4 Tympanoplasty* 1 2 3 4 EyeCanthotomy* 1 2 3 4 Corneal Transplant* 1 2 3 4 Correction of Ectropion / Entropion* 1 2 3 4 Enucleation* 1 2 3 4 Excision of Chalazion* 1 2 3 4 Integrated Orbital Implants* 1 2 3 4 HiddenLacrimal Duct Probing* 1 2 3 4 Refractive Keratoplasty* 1 2 3 4 Repair of Retinal Detachment* 1 2 3 4 Vitrectomy* 1 2 3 4 General SurgeryAbdominal Perineal Resection* 1 2 3 4 Adrenalectomy* 1 2 3 4 Bowel Resection* 1 2 3 4 Cholecystectomy* 1 2 3 4 Colostomy / Ileostomy* 1 2 3 4 Gastrectomy* 1 2 3 4 Hemicolectomy* 1 2 3 4 Hepatic Resection* 1 2 3 4 Herniorrhaphy-Femoral / Inguinal* 1 2 3 4 Hiatal Herniorrhaphy: Transabdominal* 1 2 3 4 Pancreatectomy* 1 2 3 4 Organ Procurement* 1 2 3 4 Radical Mastectomy* 1 2 3 4 Saphenous Vein Ligation and Stripping* 1 2 3 4 Splenectomy* 1 2 3 4 Thyroidectomy* 1 2 3 4 Tracheostomy* 1 2 3 4 Whipple Procedure* 1 2 3 4 G.U. and CystoCircumcision* 1 2 3 4 Cystectomy* 1 2 3 4 Cystoscopy / Cystostomy* 1 2 3 4 Hypospadias Repair* 1 2 3 4 Ileal Loop* 1 2 3 4 Kidney Repair* 1 2 3 4 Lithotripsy* 1 2 3 4 Nephrectomy* 1 2 3 4 Orchiectomy* 1 2 3 4 Penile Implant* 1 2 3 4 Prostatectomy* 1 2 3 4 T.U.R.P. / T.U.R.B.* 1 2 3 4 Ureterolithotomy* 1 2 3 4 Vasectomy* 1 2 3 4 GynecologyCesarean Section* 1 2 3 4 Dilation and Curettage* 1 2 3 4 Hysterectomy Abdominal* 1 2 3 4 Hysterectomy Vaginal* 1 2 3 4 Laser Surgery* 1 2 3 4 Radium Insertion* 1 2 3 4 Salpingo Oophorectomy* 1 2 3 4 Shirodkar Procedure* 1 2 3 4 Termination of Pregnancy* 1 2 3 4 Tubal Ligation* 1 2 3 4 Vaginal Reconstruction* 1 2 3 4 Vaginectomy* 1 2 3 4 LaparoscopicAppendectomy* 1 2 3 4 Cholecystectomy* 1 2 3 4 Colon Resection* 1 2 3 4 Hernia Repair* 1 2 3 4 NeurosurgeryAnterior Cervical Fusion* 1 2 3 4 Burr Holes for Subdural Hematoma* 1 2 3 4 Craniotomy* 1 2 3 4 Laminectomy* 1 2 3 4 Meningocele Repair* 1 2 3 4 Shunt Procedures VP / VA* 1 2 3 4 OrthopedicAmputation Leg / Arm* 1 2 3 4 Application of Halo Traction* 1 2 3 4 Arthroscopy / Arthrotomy* 1 2 3 4 Closed Pinning and Reduction of Extremities* 1 2 3 4 External Compression Devices* 1 2 3 4 Insertion of Finger Prosthesis* 1 2 3 4 O.R.I.F. Shoulder, Hip, Humerus, etc.* 1 2 3 4 Patellectomy* 1 2 3 4 Repair of Dislocation* 1 2 3 4 Spica Cast Application* 1 2 3 4 Spinal Fusion* 1 2 3 4 Transforaminal Lumbar Interbody Fusion (TLIF)* 1 2 3 4 Direct Lateral Interbody Fusion (DLIF)* 1 2 3 4 Extreme Lateral Interbody Fusion (XLIF)* 1 2 3 4 Computer-Assisted Navigation* 1 2 3 4 360s* 1 2 3 4 540s* 1 2 3 4 Tendon Implants and Reanastomosis* 1 2 3 4 Total Joint Replacement Knee, Hip, Shoulder* 1 2 3 4 ThoracicBronchoscopy* 1 2 3 4 Chest Tube Set-Up Type* 1 2 3 4 Hiatal Hernia* 1 2 3 4 Lung / Wedge Resection* 1 2 3 4 Pneumonectomy / Lobectomy* 1 2 3 4 Sternal Splitting* 1 2 3 4 Thoracotomy* 1 2 3 4 PlasticsAbdominoplasty / Abdominal Lipectomy* 1 2 3 4 Augmentation Mammoplasty* 1 2 3 4 Cleft Lip / Palate Repair* 1 2 3 4 Dermabrasion* 1 2 3 4 Digital Flexor Tendon Repair* 1 2 3 4 Liposuction* 1 2 3 4 Myelomeningocele Repair* 1 2 3 4 Otoplasty* 1 2 3 4 Rhinoplasty* 1 2 3 4 Reduction of Facial Fracture* 1 2 3 4 Scar Revision* 1 2 3 4 Skin Meshing* 1 2 3 4 Split Thickness Skin Grafting* 1 2 3 4 Age Specific CompetencyNewborn / Neonate (Birth - 30 days)* 1 2 3 4 Infant (1 month - 1 year)* 1 2 3 4 Toddler (1 - 3 years)* 1 2 3 4 Preschooler (3 - 5 years)* 1 2 3 4 School Age Child (5 - 12 years)* 1 2 3 4 Adolescents (12 - 18 years)* 1 2 3 4 Young Adults (18 - 39 years)* 1 2 3 4 Middle Adults (39 - 64 years)* 1 2 3 4 Older Adults (64 - 79 years)* 1 2 3 4 Elderly Adults (Over 79+ years)* 1 2 3 4