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Please mark your level of experience
For the skills listed below please check if you are:
(E) Expert - serves as resource
(P) Proficient - performs daily or weekly
(L) Limited - less than 6 times a year
(N) No Experience - observed only
To StaffingMedical USA Employees:
Please rate your ability to perform these skills as accurately as possible
by checking the
appropriate boxes.
The information I have given here is true and accurate to the best of my
knowledge.
I authorize StaffingMedical USA to release this checklist to client hospitals
for the
purpose of placing me on a travel assignment.
Name
Date
Email
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Age Specific
Practice Critera
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| Cardiovascular |
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| EENT |
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| Endocrine/Metabolic |
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| Gastrointestinal |
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| Genitourinary/Renal |
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| Infectious Diseases |
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IV Therapy
/Phlebotomy/Invasive Procedures |
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| Miscellaneous |
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| Neurological |
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| Orthopedics |
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| Pain Management |
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| Pediatrics |
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| Pulmonary |
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| Trauma /Shock |
| Care of Patient with |
| | E | P | L | N |
| Bites, Animal |
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| Bites, Human |
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| Bites, Venomous snake |
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| Bites, Venomous spider |
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| Burns, Rule of nines |
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| Burns, First degree |
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| Burns, Second degree |
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| Burns, Third degree |
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| Dehydration |
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| Electrocution |
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| Gunshot/Stab wound |
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| Hazardous materials exposure |
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| Heat exhaustion /stroke |
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| Hypothermia |
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| Major trauma |
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| Minor trauma |
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| Radiation exposure |
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| Shock, Anaphylactic |
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| Shock, Cardiogenic |
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| Shock, Hypovelemic |
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| Shock, Neurogenic |
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| Shock, Septic |
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| Traumatic Amputation |
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| Woman's Health |
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| Wound Management |
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Performance
Evaluation |
Signature Date
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