Please rate your experience / frequency within the last year

0 = No Experience / Observed Only
1 = Limited Experience / Rarely Done (<6 times/year)
2 = May Need Some Review / Occasionally Done (1 – 2 times/month)
3 = Experienced / Frequently Done (daily or weekly)

MM slash DD slash YYYY

AGE OF CLIENTS:

Newborn/Neonate (birth to 30 days)(Required)
Infant (31 days to 12 months)(Required)
Toddler/Preschool (13 months to 5 years)(Required)
School Age Child/adolescent (6 years to 18 years)(Required)
Young Adults Middle Adult (19 years to 64 years)(Required)
Older Adults/Elderly (65+years)(Required)

CIRCULATING ROLE (PAV)

Airway Maintenance(Required)
Arm Cases(Required)
Biopsy(Required)
Co-Ox Setup Q.C., Run Sample(Required)
Defi bribulator Setup/Use(Required)
IABP(Required)
Power Injector Setup/Use(Required)
Left Heart Catheterization(Required)
Right Heart Catheterization(Required)
PTCA/Stents/Ballons(Required)
Radiation Protection(Required)
Atherectomy(Required)
Permanent Pacemaker(Required)
Temporary Pacemaker(Required)
Setting Threshold of Pacemakers(Required)
Rotablator(Required)
Sphygmomanometer Monitoring(Required)
Transducer Setup/Calibration(Required)
Run Angiojet Machine(Required)
IVUS(Required)

CIRCULATING ROLE

Biopsy(Required)
Handoff Reports(Required)
Left Heart Caths(Required)
Right Heart Caths(Required)
Coronary Intervention(Required)
Hematoma Recognition & Mgt(Required)
Coronary Atherectomy(Required)
IVUS(Required)
Intra Aortic Balloon Pump(Required)
Rotablator(Required)
FFR(Required)

SCRUB POSITION

Left Heart Catheterization(Required)
Right Heart Catheterization(Required)
Coronary Intervention(Required)
Stent Implantation(Required)
Rotational Coronary Atherectomy(Required)
IVUS(Required)
Intra Aortic Balloon Pump(Required)
Biopsy(Required)
Closure Device(Required)
Temporary Pacemakers(Required)
Angiojet(Required)
Radial(Required)
Brachial(Required)
Peripherals(Required)
FFR(Required)
Impella(Required)
PPM(Required)
ICD(Required)
BiV(Required)
Loop Recorder(Required)
Structural Heart(Required)
Manifold(Required)
ACIST/Medrad(Required)
Hybrid OR(Required)
Atherectomy(Required)
Simultaneously Scrub & Pan Xray Table(Required)
Sheath Pulls(Required)

CATH LAB / ANGIO / SPECIALS

Equipment(Required)
Phillips(Required)
Siemens(Required)
Toshiba(Required)
GE(Required)
Siemens Artis Zeego(Required)
Shimadzu(Required)
Cannon Alphenix(Required)

OTHER:

HEMODYNAMIC MONITORING EQUIP.

GE MacLab Marquette(Required)
Mennen(Required)
Merge Cardio/Camtronics VERICIS(Required)
McKesson(Required)
Phillips Xper IM/WITT(Required)
Siemens Sensis(Required)
Co-Ox Setup Q.C., Run Sample(Required)

EMRs

Cannon Alphenix(Required)
Cerner(Required)
Epic(Required)
GE(Required)
Mac Lab(Required)
McKesson(Required)
Meditech(Required)
Phillips(Required)
Shimadzu(Required)
Siemens(Required)
Siemens Artis Zeego(Required)
Toshiba(Required)
Xper(Required)

OTHER SKILLS