Surgical Tech 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

AKA/BKA (amputation)(Required)

Radical Mastectomy(Required)

Abdominal-Perineal Resection(Required)

Cholecystectomy (Open)(Required)

Exploratory Laparotomy(Required)

Appendectomy(Required)

Laparoscopic Procedure-Cholecystectomy(Required)

Laparoscopic Procedure-Appendectomy(Required)

Laparoscopic Procedure-Hernia(Required)

Laparoscopic Procedure-Nissan(Required)

Laparoscopic Procedure-Colectomy(Required)

Gastrectomy(Required)

Inguinal/Ventral Hernia Repair(Required)

Spienectomy(Required)

Bowel Resection/Colostomy(Required)

Thyroidectomy(Required)

Rectal Procedures(Required)

Esophagascopy/Gastroscopy(Required)

Pediatric Case-Inguinal Hernia Repair(Required)

Pediatric Case-Pyloric Stenosis(Required)

Pediatric Case-Circumcision(Required)

Pediatric Case-Exploratory Laparotomy(Required)

VASCULAR SURGERY

Carotid Endarterectomy(Required)

Abdominal Aortic Aneurysm(Required)

Femoral-Popliteal By-pass Graft (Insitu)(Required)

Femoral-Popliteal By-pass Graft (Graph)(Required)

Portacath, Tesio, Hickman(Required)

AV Shunt(Required)

Thrombecomy(Required)

Pacemaker Insertion(Required)

Arterial Stenting/Intra-Operative Angioplasty(Required)

Subclavin/Carotid By-pass(Required)

CARDIAC/THORACIC/VASCULAR

Coronary Artary By-pass(Required)

Mitral Valve Repair/Replacement(Required)

Aortic Valve Replacement(Required)

Multiple Valve Transposition(Required)

Septal Defects(Required)

Ventricular Aneurysm Repair(Required)

Bring Back Heart(Required)

Pericardial Window(Required)

Intra-Aortic Balloon Insertion(Required)

Heartport or Similar CABG(Required)

Thoraco approach Mid-Cab(Required)

Aortic Arch Replacement/Valve Conduit(Required)

Mechanical Heart/LVAD(Required)

Pediatric Hearts(Required)

Tetrology of Fallot(Required)

Chamberlain Procedure(Required)

Femoral Artery Cannulation(Required)

AICD Insertion(Required)

Saphenous Vein Harvest(Required)

Endoscopic Vein Harvest(Required)

Gastric Artery Harvest(Required)

Radial Vein Harvest(Required)

Carotid Endarterectomy(Required)

Abdominal Aortic Aneurysm(Required)

Femoral-Popliteal By-pass Graft(Required)

Thrombectomy(Required)

AV Shunt(Required)

Pacemaker Insertion(Required)

Insertion Vena cava Filter(Required)

Portacath, Tesio, Hickman Placement(Required)

Thoracotomy(Required)

Thoracoscopy(Required)

Insertion Chest Tubes(Required)

Esophageal Repair(Required)

Pneurnonectorny/Lobectomy(Required)

Mediastinodcopy(Required)

Desendind Aortic Repair(Required)

Arterial Stenting/Intra-Operative Angiopiasty(Required)

ORTHODEPIDS

Total Hip Replacement(Required)

Bipolar Hip(Required)

Compression Hip Screw(Required)

Total Knee Replacement(Required)

Knee Arthoscopy(Required)

ACL Knee Repair(Required)

Harrington Rod or Similar(Required)

I.M. Rodding(Required)

Hand & Foot Procedures(Required)

Mini, Standard, Large Fragment Screws & Plates(Required)

External Fixation(Required)

Shoulder Repair(Required)

Shoulder Arthoscopy(Required)

Spinal Fusion(Required)

Cast Application(Required)

Fracture Table Set-up(Required)

Drills, Saws and Reamers(Required)

GYNECOLOGY

D&C(Required)

Diagnostic Laparascope(Required)

Laparoscopic Assisted Vaginal Hysterectomy(Required)

Abdominal Hysterectomy(Required)

Varinal Hysterectomy(Required)

Anterior/Posterior Repair(Required)

MMK(Marshall Marchetti Krantz)(Required)

Tuboplasty(Required)

BTL(Bilateral Tubal Ligation)(Required)

C-Sections(Required)

UROLOGY

Radical Prostatectomy(Required)

Radical Lymph Node Dissection(Required)

Insertion Penile Prostesis(Required)

Hydrocelectomy(Required)

Cystoscopy(Required)

Ureteroscopy(Required)

TURP/TURST(Required)

Ultrasonic Lithotripsy(Required)

NEUROLOGY

Cervical Laminectomy(Anterior)(Required)

Cervical Laminectomy(Posterior)(Required)

Lumbar Laminectomy, Discectomy(Required)

Percutaneous Micro Discectomy(Required)

Craniotomy For Tumor(Required)

Craniotomy For Aneurysm(Required)

Burr Holes(Required)

VP Shunts(Required)

Transphenoidal Hypothypectomy(Required)

Carpal Tunnel Repair(Required)

Harrington Rod or Similar(Required)

PLASTICS

Mammoplasty(Required)

Facelifts(Required)

Skin Grafts(Required)

Rhinopiasty(Required)

Abdorninalplasty(Required)

Blepharopiasty(Required)

Otoplasty(Required)

Muscle Flaps(Required)

E.N.T.

Middle Ear Cases(Required)

T&A(Required)

Myringotomy(Required)

Tympanoplasty(Required)

Radical Neck Dissection(Required)

Septoplasty(Required)

Sinus Endoscopy(Required)

TRAUMA SURGERY

Transplant Surgery(Required)

Organ Procurement(Harvest)(Required)

THORACIC SURGERY

Thoracotomy(Required)

Thoracoscopy(Required)

Insertion Chest Tubes(Required)

Esophageal Repair(Required)

Pneumonectomy/Lobectomy(Required)

OTHER SKILLS

List here(Required)

Please rate your experience / frequency within the last year

AGE OF CLIENTS:

GENERAL SURGERY

VASCULAR SURGERY

CARDIAC/THORACIC/VASCULAR

ORTHODEPIDS

GYNECOLOGY

UROLOGY

NEUROLOGY

PLASTICS

E.N.T.

TRAUMA SURGERY

THORACIC SURGERY

OTHER SKILLS

.

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