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)

GENERAL SKILLS

AKA/BKA (amputation(Required)
Care of Patients in Restraints(Required)
Lifting/Transferring Devices(Required)
Accudose(Required)
Promanager Rx(Required)
Temporal Bones(Required)
Metro(Required)
Pyxis(Required)
Omnicell(Required)
Allscripts(Required)
eCLinicalWorks(Required)
McKesson(Required)
Soarian(Required)
Care360(Required)
EPIC(Required)
Meditech(Required)
Cerner(Required)
MACLAB(Required)
PACS(Required)
Alaris(Required)
Baxter(Required)
IVAC(Required)
Alibaba(Required)
Braun(Required)
Zynomed(Required)
Bard(Required)
CADD(Required)
Knowledge of "Do Not Use Abbreviations(Required)
Do you have charge/supervisor experience?(Required)
Knowledge of current Joint Commission National Patient Safety Goals(Required)
Knowledge/familiarity with HCAHPS scores(Required)

PRE-PROCEDURE

Allen Test(Required)
Doppler(Required)
EKG lead/pad placement(Required)
Blood Pressure Invasive and Noninvasive(Required)

HEMODYNAMIC MONITORING

Monitoring/Recording cases(Required)
Coagulation Interpretation(Required)
Waveform Assessment(Required)

CARDIOVASCULAR

Hematoma Recognition/Management(Required)
Radial, brachial, femoral, pedal pulse checks(Required)

PULMONARY

Set up Oxygen Delivery Devices(Cannula, NRBM, Ambu)(Required)
Assist with Intubation(Required)
Suction equipment (oral,NP, In line)(Required)

PROCEDURES DIAGNOSTIC AND INTERVENTIONAL

Panning Table(Required)
Moving Image Intensifi er, Knowledge of views( RAO, LAO, cranial, caudal)(Required)
Scrub Diagnostic Procedures(Required)
Scrub Interventional Procedures(Required)
Specimen Radiographs(Required)
Selective Radiographs(Required)
TIPPS Procedure(Required)
Angioplasty/Stent(Required)
Thrombolysis/Thrombectomy(Required)
Embolic Protection Devices(Required)
Cerebral Coiling(Required)
PVA(Required)
Gelfoam(Required)
Cerebral Angiography(Required)
Carotid Arteriogram(Required)
Brachial Arteriogram(Required)
Aortogram(Required)
Femoral Arteriogram(Required)
Renal Arteriogram(Required)
Pulmonary Arteriogram(Required)
Venogram(Required)
Endografts(Required)
AV Fistulas(Required)

PACEMAKERS

Permanent Pacemaker/AICD(Required)
Temporary Epicardial/Transthoracic Pacing(Required)
Temporary External /transvenous pacing(Required)

CARE OF PATIENT DURING EMERGENCY PROCEDURES

Emergency Defi brillation/ Cardioversion(Required)
Anaphylaxis(Required)
Vasovagal Response(Required)
Pneumothorax(Required)
Cardiogenic Shock(Required)
Embolism(Required)
Cardiac/Respiratory arrest(Required)

EQUIPMENT/SUPPLIES

ACT Machine(Required)
Hemochron(Required)
Power Injector(Required)
Manual Pressure Hold(Required)
Femostop/ C-Clamp(Required)

OTHER SKILLS