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

PROCESSING:

Single Instruments(Required)
Wrapped Sets(Required)
Instrument Containers(Required)
Endoscopes(Required)
Repairs(Required)

SAFETY PROCEDURES:

Protective Attire(Required)
Standard Precautions(Required)
Sharps Handling(Required)
Managing Biohazardous Waste(Required)

DECONTAMINATION:

Use of Washers(Required)
Washer/Disinfectors(Required)
Washer/Sterilizers(Required)
Detergent Use and Refills(Required)
Chemical Agents for Decontamination(Required)
Ultrasonic Cleaner(Required)
Equipment (e.g. crash carts, IV pumps)(Required)

STERILIZATION – Steam Autoclave::

Gravity Displacement(Required)
Prevacuum(Required)
Flash(Required)

Sterility Assurance Tests:

Bowie Dick(Required)
Biological(Required)
Chemical(Required)

Steam Sterilization:

Load Documentation(Required)
Cart Loading(Required)
Testing Validation Procedures(Required)
Trouble Shooting(Required)

Gas (ETOH):

Load Documentation(Required)
Loading Procedures(Required)
Testing Validation Procedures(Required)
Trouble Shooting(Required)

Sterrad:

Load Documentation(Required)
Loading Procedures(Required)
Testing Validation Procedures(Required)
Trouble Shooting(Required)

Steris:

Load Documentation(Required)
Tray Loading(Required)
Testing Validation Procedures(Required)
Trouble Shooting(Required)

ASSEMBLY AND PREPARATION:

Instrument Set Assembly(Required)
Selection of Appropriate Wrapping Material(Required)
Assembly of Peel Pack Items(Required)
Preparation of Hard Instrument Containers(Required)
Wrapping Procedure(Required)
Selection of Sterilization Tapes(Required)
Towel/Linen Folding(Required)
Labeling Standards(Required)
Peel Pack/Heat Sealing(Required)
Instrument Count Sheets(Required)
Physician Preference Cards(Required)
Case Picking(Required)
Sterile Storage Standards(Required)

SPECIALTY EQUIPMENT PROCESSING:

General(Required)
Cardiac(Required)
Endoscopy (5 – FU)(Required)
Laparoscopic(Required)
Neurology(Required)
OB/GYN(Required)
Ophthalmology(Required)
Orthopedics(Required)
Plastics(Required)
Robotics(Required)
Urology(Required)

OTHER SKILLS