Certified Surgical First Assistant Skills Checklist

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)

Full Name(Required)

Email(Required)

Send to(Required)

Date(Required)

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)

GENERAL SURGERY

Abdominal Perineal Resection(Required)

Adrenalectomy(Required)

Anal Fistulectomy(Required)

Breast Biopsy(Required)

Colostomy / Ileostomy(Required)

Gastrectomy(Required)

Gastroplasty(Required)

Hemorrhoidectomy(Required)

Hepatic Resection(Required)

Hernia Repair(Required)

Herniorrhaphy(Required)

Hiatal Herniorrhaphy, Transabdominal / Transthoracic(Required)

Hickman / Groshong / Port-A-Cath Insertion(Required)

Hydrocelectomy(Required)

Imperforate Anus Reconstruction(Required)

LeVeen-Peritoneal Shunt(Required)

Lumbar Sympathectomy(Required)

Mediastinoscopy(Required)

Omphalocele Repair(Required)

Pancreatectomy(Required)

Pilonidal Cystectomy(Required)

Pyloric Stenosis(Required)

Radical Mastectomy(Required)

Saphenous Vein Ligation and Stripping(Required)

Sentinel Node Biopsy(Required)

Splenectomy(Required)

Thyroidectomy(Required)

Vagotomy(Required)

Whipple(Required)

EAR, NOSE, & THROAT

Acoustic Neuroma(Required)

Adenoidectomy(Required)

Cleft Lip / Palate Repair(Required)

Cochlear Implantation(Required)

Ethmoidectomy(Required)

Fenestration Procedure(Required)

Frontal Flap Sinus Procedure(Required)

Glossectomy(Required)

Laryngectomy(Required)

Mandibulectomy(Required)

Maxillectomy(Required)

Nasal Polypectomy(Required)

Radical Neck Dissection(Required)

Sinus Endoscopy(Required)

Sinusotomy(Required)

Tonsillectomy(Required)

Tracheostomy(Required)

Tympanoplasty(Required)

ENDOSCOPIC PROCEDURES

Bronchoscopy(Required)

Colonoscopy(Required)

Culdoscopy(Required)

Cystoscopy(Required)

Esophagoscopy(Required)

Gastroscopy(Required)

Hysteroscopy(Required)

LAPAROSCOPIC PROCEDURES

Appendectomy(Required)

Cholecystectomy / Cholangiogram(Required)

Colon Resection(Required)

Hernia Repair(Required)

Nissen Fundoplication(Required)

Laryngoscopy & Microlaryngoscopy(Required)

Mediastinoscopy(Required)

Pelviscopy(Required)

Sigmoidoscopy(Required)

Thoracoscopy(Required)

GYNECOLOGY

Cesarean Section(Required)

Dilation and Curettage (D&C)(Required)

Hysterectomy, Abdominal(Required)

Hysterectomy, Vaginal(Required)

Laparoscopy(Required)

Marshall Marchetti(Required)

Marsupialization, Bartholin Cyst(Required)

Ovarian Cystectomy(Required)

Radical Hysterectomy(Required)

Radium Insertion(Required)

Salpingoplasty(Required)

Suction Curettage(Required)

TAH/BSO(Required)

Vaginal Reconstruction(Required)

NEUROLOGY

Acoustic Neuroma(Required)

Anterior Cervical Fusion(Required)

Anterior Laparoscopic Spine Procedures(Required)

A-V Malformation(Required)

Burr Holes(Required)

Carotid Endarterectomy(Required)

Cervical Laminectomy(Required)

Clipping of Aneurysm(Required)

Cranioplasty(Required)

Craniotomy for Tumor Excision(Required)

Discectomy(Required)

Hypophysectomy(Required)

Insertion Nerve Stimulators / Medication Pumps(Required)

Meningocele Repair(Required)

Shunt Procedure(Required)

Spine Fusion(Required)

Ulnar Nerve Transfer(Required)

Ventriculostomy(Required)

OPHTHALMOLOGY

Cataract Extraction(Required)

Corneal Transplant(Required)

Dacryocystectomy(Required)

Dacryocystorhinostomy(Required)

Enucleation(Required)

Iridectomy(Required)

Orbital Implant(Required)

Phacoemulsification(Required)

Pterygium Repair(Required)

Vitrectomy(Required)

ORAL

Closed Reduction Facial Fractures / Wiring(Required)

Fractured Jaws, Mandibular, and Zygomatic(Required)

LeFort Osteotomies(Required)

Maxillary Procedure With Graft(Required)

Pediatric Dentistry(Required)

Sagittal Osteotomy(Required)

Temporomandibular Joint (TMJ) With Arthroplasty(Required)

TMJ Exploration(Required)

ORTHOPEDICS

Acetabular / Pelvic ORIF(Required)

Achilles Tendon Repair(Required)

ACL Repair(Required)

Amputation – Leg , Arm(Required)

Application of External Fixators(Required)

Arthroscopic Surgery(Required)

Arthrotomy(Required)

Bunionectomy(Required)

Capsulorrhaphy(Required)

Carpal Tunnel Release(Required)

Closed Reduction Fracture(Required)

Extraction(Required)

Fracture Table Use(Required)

Hand Surgery(Required)

Harrington Rod Instrumentation and / or Dwyer Procedure(Required)

Iliac Crest Bone Graft(Required)

IM Rodding(Required)

Insertion Austin Moor Hip Prosthesis(Required)

Intramedullary Rods(Required)

Laminectomy(Required)

Open Reduction Fracture(Required)

Patellectomy(Required)

Putti Platt / Bankart Procedure / Rotator Cuff Repair(Required)

Reimplantation of Digits(Required)

Spinal Fusion(Required)

Total Hip(Required)

Total Joint Replacements / Revisions(Required)

Total Knee(Required)

Total Shoulder(Required)

PLASTICS

Abdominal Lipectomy(Required)

Augmentation Mammoplasty(Required)

Blepharoplasty(Required)

Dermabrasion(Required)

Face Lift(Required)

Mentoplasty(Required)

Otoplasty(Required)

Reduction Mammoplasty(Required)

Rhinoplasty(Required)

Scar Revision(Required)

Skin Grafts(Required)

Tissue Expanders(Required)

UROLOGY

Hypospadias Repair(Required)

Implants, Penile, Testicular(Required)

Nephrectomy(Required)

Orchiopexy(Required)

Perineal(Required)

Prostatectomy(Required)

Pyeloplasty(Required)

Radical Node Dissection(Required)

Supra-Pubic(Required)

Suprapubic Prostatectomy(Required)

TURP(Required)

Vasectomy(Required)

Vasovasostomy(Required)

VASCULAR

A-V Access Graft(Required)

AV Fistula Shunt(Required)

Carotid Endarterectomy(Required)

Fem/Pop Graft(Required)

Peripheral Vascular Bypass Procedures(Required)

Thrombectomy / Embolectomy(Required)

Vena Cava Filter / Umbrella(Required)

Vena Cava Ligation(Required)

ANESTHESIA

Assist With Intubation(Required)

Conscious Sedation(Required)

Management of Malignant Hyperthermia Crisis Sedation(Required)

EQUIPMENT

Argon Beam Coagulator(Required)

Arthroscopy Cameras(Required)

Bair Hugger(Required)

Blood / Fluid Warmer(Required)

Bovie Electrosurgical Unit(Required)

Camera / Video Systems(Required)

Cardiac Monitor and Pacemaker(Required)

Cell Saver(Required)

Cidex Soak(Required)

Defibrillator / Pacer(Required)

Dermatome(Required)

Drills(Required)

3-M Maxi Driver(Required)

Codman Craniotome(Required)

Hall Air Driver(Required)

Hall Dental(Required)

Hall Neurotome(Required)

Midax Rex / Anspach(Required)

Minidriver(Required)

Stryker Drills(Required)

Surgairtome(Required)

Synthes A-O Drill(Required)

Emerson Thoracic Pump(Required)

Ethylene Oxide Sterilizer – AMSCO(Required)

Flash Autoclave(Required)

Hypo / Hyperthermia Unit(Required)

Intestinal Stapling Devices(Required)

EEA(Required)

GIA(Required)

LDS(Required)

TA(Required)

Kreiselman Resuscitator(Required)

Laser(Required)

CO2(Required)

Eye(Required)

Yag(Required)

Mesh Graft(Required)

Nerve Stimulator(Required)

Nitrous Oxide Bank(Required)

Ohio Suction Units(Required)

Orthopedic(Required)

Pleur-Evac Disposable Chest Drainage(Required)

Pneumatic Tourniquet(Required)

Sterrad Machine(Required)

Steris Unit(Required)

Suction Unit, Disposable(Required)

Tele – Thermometer(Required)

Ultrasonic Cleaner – AMSCO(Required)

Vac Pac Positioner(Required)

Vacuum Curettage(Required)

PHLEBOTOMY / IV THERAPY

Equipment & Procedures(Required)

Administration of Blood / Blood Products(Required)

Packed Red Blood Cells(Required)

Assist With IA / IV Therapy(Required)

Insertion of A -Lines(Required)

Insertion of CVP Jugular / Subclavian(Required)

Insertion of Swan – Ganz(Required)

Drawing Blood from Central Line(Required)

Drawing Venous Blood(Required)

Starting IVs(Required)

Angiocath(Required)

BACKGROUND EXPERIENCE

Small Hospital(Required)

Large Hospital(Required)

Outpatient(Required)

Acute Care / Hospital(Required)

Cancer Center(Required)

Clinic(Required)

Managed Care(Required)

SNF / Long Term Care(Required)

Home Health(Required)

OTHER SKILLS

List here(Required)

Please rate your experience / frequency within the last year

AGE OF CLIENTS:

GENERAL SURGERY

EAR, NOSE, & THROAT

ENDOSCOPIC PROCEDURES

LAPAROSCOPIC PROCEDURES

GYNECOLOGY

NEUROLOGY

OPHTHALMOLOGY

ORAL

ORTHOPEDICS

PLASTICS

UROLOGY

VASCULAR

ANESTHESIA

EQUIPMENT

PHLEBOTOMY / IV THERAPY

BACKGROUND EXPERIENCE

OTHER SKILLS

.

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