Perioperative Skills Checklist         

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This profile is for use by Perioperative nurses with more than one year experience in their discipline and specialty. It will not be a determining factor for employment but it may aid in promoting yourself at the Interview.

Please enter your full legal name as it appears on your Social Security Card.


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 Date

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Please indicate your level of experience by checking the applicable box.
A. Theory, no practice C. Two-plus years experience
B. One - two years experience  

A. EAR, NOSE & THROAT SCRUB CIRCULATE
  1. Adenoidectomy | A |     | B |     | C | | A |     | B |     | C |
  2. Caldwell - Luc | A |     | B |     | C | | A |     | B |     | C |
  3. Cleft lip/palate repair | A |     | B |     | C | | A |     | B |     | C |
  4. Closed reduction nasal fracture | A |     | B |     | C | | A |     | B |     | C |
  5. Ethmoidectomy | A |     | B |     | C | | A |     | B |     | C |
  6. Excision of salivary gland tumor | A |     | B |     | C | | A |     | B |     | C |
  7. Fenestration procedure | A |     | B |     | C | | A |     | B |     | C |
  8. Frontal flap sinus procedure | A |     | B |     | C | | A |     | B |     | C |
  9. Glossectomy | A |     | B |     | C | | A |     | B |     | C |
  10. Laryngectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Mandibulectomy | A |     | B |     | C | | A |     | B |     | C |
  12. Mastoidectomy | A |     | B |     | C | | A |     | B |     | C |
  13. Maxillary advancement with hip graft | A |     | B |     | C | | A |     | B |     | C |
  14. Maxillectomy | A |     | B |     | C | | A |     | B |     | C |
  15. Myringoplasty | A |     | B |     | C | | A |     | B |     | C |
  16. Myringotomy/with PE tube insertion | A |     | B |     | C | | A |     | B |     | C |
  17. Nasal polypectomy | A |     | B |     | C | | A |     | B |     | C |
  18. Open reduction facial fracture | A |     | B |     | C | | A |     | B |     | C |
  19. Open reduction nasal fracture | A |     | B |     | C | | A |     | B |     | C |
  20. Parotidectomy | A |     | B |     | C | | A |     | B |     | C |
  21. Pharyngeal flap procedure | A |     | B |     | C | | A |     | B |     | C |
  22. Radical neck dissection | A |     | B |     | C | | A |     | B |     | C |
  23. Ranulectomy | A |     | B |     | C | | A |     | B |     | C |
  24. Rhinoplasty/septoplasty | A |     | B |     | C | | A |     | B |     | C |
  25.Selective osteotomy of maxilla/mandible | A |     | B |     | C | | A |     | B |     | C |
  26. Sinus endoscopy | A |     | B |     | C | | A |     | B |     | C |
  27. Sinusotomy | A |     | B |     | C | | A |     | B |     | C |
  28. Stapedectomy | A |     | B |     | C | | A |     | B |     | C |
  29. Submucous resection | A |     | B |     | C | | A |     | B |     | C |
  30. Tonsillectomy | A |     | B |     | C | | A |     | B |     | C |
  31. Tracheostomy | A |     | B |     | C | | A |     | B |     | C |
  32. Tympanoplasty | A |     | B |     | C | | A |     | B |     | C |

B. ENDOSCOPIC PROCEDURES SCRUB CIRCULATE
  1. Bronchoscopy | A |     | B |     | C | | A |     | B |     | C |
  2. Colonoscopy | A |     | B |     | C | | A |     | B |     | C |
  3. Culdoscopy | A |     | B |     | C | | A |     | B |     | C |
  4. Cystoscopy | A |     | B |     | C | | A |     | B |     | C |
  5. Esophagoscopy | A |     | B |     | C | | A |     | B |     | C |
  6. Gastroscopy | A |     | B |     | C | | A |     | B |     | C |
  7. Hysteroscopy | A |     | B |     | C | | A |     | B |     | C |
  8. Laparoscopic procedures    
    a. Appendectomy | A |     | B |     | C | | A |     | B |     | C |
    b. Cholecystectomy/cholangiogram | A |     | B |     | C | | A |     | B |     | C |
    c. Colon resection | A |     | B |     | C | | A |     | B |     | C |
    d. Hernia repair | A |     | B |     | C | | A |     | B |     | C |
    e. Nissen fundoplication | A |     | B |     | C | | A |     | B |     | C |
    f. Salpingo-oophorectomy | A |     | B |     | C | | A |     | B |     | C |
    g. Tubal ligation | A |     | B |     | C | | A |     | B |     | C |
    h. Vaginal hysterectomy | A |     | B |     | C | | A |     | B |     | C |
  9. Laryngoscopy & microlaryngoscopy | A |     | B |     | C | | A |     | B |     | C |
  10. Mediastinoscopy | A |     | B |     | C | | A |     | B |     | C |
  11. Pelviscopy | A |     | B |     | C | | A |     | B |     | C |
  12. Sigmoidoscopy | A |     | B |     | C | | A |     | B |     | C |
  13. Thoracoscopy | A |     | B |     | C | | A |     | B |     | C |

C. GENERAL SURGERY SCRUB CIRCULATE
  1. Abdominal perineal resection | A |     | B |     | C | | A |     | B |     | C |
  2. Adrenalectomy | A |     | B |     | C | | A |     | B |     | C |
  3. Anal fissurectomy | A |     | B |     | C | | A |     | B |     | C |
  4. Appendectomy | A |     | B |     | C | | A |     | B |     | C |
  5. Breast biopsy | A |     | B |     | C | | A |     | B |     | C |
  6. Colectomy | A |     | B |     | C | | A |     | B |     | C |
  7. Colostomy/ileostomy | A |     | B |     | C | | A |     | B |     | C |
  8. Gastrectomy | A |     | B |     | C | | A |     | B |     | C |
  9. Gastroplasty | A |     | B |     | C | | A |     | B |     | C |
  10. Hemorrhoidectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Hepatic resection | A |     | B |     | C | | A |     | B |     | C |
  12. Herniorrhaphy - femoral, inguinal, umbilical | A |     | B |     | C | | A |     | B |     | C |
  13. Hiatal herniorrhaphy, transabdominal/transthoracic | A |     | B |     | C | | A |     | B |     | C |
  14. Hickman/Groshong/Portacath insertion | A |     | B |     | C | | A |     | B |     | C |
  15. Hydrocelectomy | A |     | B |     | C | | A |     | B |     | C |
  16. Imperforate anus reconstruction | A |     | B |     | C | | A |     | B |     | C |
  17. Lumbar sympathectomy | A |     | B |     | C | | A |     | B |     | C |
  18. Omphalocele repair | A |     | B |     | C | | A |     | B |     | C |
  19. Pancreatectomy/pancreatogram | A |     | B |     | C | | A |     | B |     | C |
  20. Pilonidal cystectomy | A |     | B |     | C | | A |     | B |     | C |
  21. Portal caval shunt | A |     | B |     | C | | A |     | B |     | C |
  22. Pyloric stenosis | A |     | B |     | C | | A |     | B |     | C |
  23. Radical mastectomy | A |     | B |     | C | | A |     | B |     | C |
  24. Saphenous vein ligation and stripping | A |     | B |     | C | | A |     | B |     | C |
  25. Sentinel node biopsy | A |     | B |     | C | | A |     | B |     | C |
  26. Splenectomy | A |     | B |     | C | | A |     | B |     | C |
  27. Tenchkhoff catheter placement | A |     | B |     | C | | A |     | B |     | C |
  28. Thyroglossal duct cyst excision | A |     | B |     | C | | A |     | B |     | C |
  29. Thyroidectomy | A |     | B |     | C | | A |     | B |     | C |
  30. Tracheostomy | A |     | B |     | C | | A |     | B |     | C |
  31. Vagotomy  A |     | B |     | C | | A |     | B |     | C |

D. GYNECOLOGY SCRUB CIRCULATE
  1. Cesarean section | A |     | B |     | C | | A |     | B |     | C |
  2. Colpotomy | A |     | B |     | C | | A |     | B |     | C |
  3. Dilation and curettage (D & C) | A |     | B |     | C | | A |     | B |     | C |
  4. Hysterectomy, abdominal | A |     | B |     | C | | A |     | B |     | C |
  5. Hysterectomy, vaginal | A |     | B |     | C | | A |     | B |     | C |
  6. Marshall - Marchetti | A |     | B |     | C | | A |     | B |     | C |
  7. Marsupialization, Bartholin cyst | A |     | B |     | C | | A |     | B |     | C |
  8. Ovarian cystectomy | A |     | B |     | C | | A |     | B |     | C |
  9. Radium insertion | A |     | B |     | C | | A |     | B |     | C |
  10. Sacral spinus fixation | A |     | B |     | C | | A |     | B |     | C |
  11. Shirodkar procedure | A |     | B |     | C | | A |     | B |     | C |
  12. Suction curettage | A |     | B |     | C | | A |     | B |     | C |
  13. Vaginal reconstruction | A |     | B |     | C | | A |     | B |     | C |
  14. Vaginectomy/vulvectomy | A |     | B |     | C | | A |     | B |     | C |

E. NEUROLOGY SCRUB CIRCULATE
  1. A-V malformation | A |     | B |     | C | | A |     | B |     | C |
  2. Anterior cervical fusion | A |     | B |     | C | | A |     | B |     | C |
  3. Anterior laparoscopic spine procedures | A |     | B |     | C | | A |     | B |     | C |
  4. Anterior lumbar interbody fusion (ALIF) | A |     | B |     | C | | A |     | B |     | C |
  5. Burr holes for subdural hematoma | A |     | B |     | C | | A |     | B |     | C |
  6. Carotid ligation | A |     | B |     | C | | A |     | B |     | C |
  7. Cervical sympathectomy | A |     | B |     | C | | A |     | B |     | C |
  8. Craniectomy for decompression fracture | A |     | B |     | C | | A |     | B |     | C |
  9. Cranioplasty/craniotomy    
    a. Clipping of aneurysm | A |     | B |     | C | | A |     | B |     | C |
    b. Tumor excision | A |     | B |     | C | | A |     | B |     | C |
    c. Using stealth equipment (stealth craniotomy) | A |     | B |     | C | | A |     | B |     | C |
  10. Discectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Hypophysectomy | A |     | B |     | C | | A |     | B |     | C |
  12. Insertion nerve stimulators/medication pumps | A |     | B |     | C | | A |     | B |     | C |
  13. Laminectomy | A |     | B |     | C | | A |     | B |     | C |
  14. Myelomeningocele repair | A |     | B |     | C | | A |     | B |     | C |
  15. Pedicle screw insertion | A |     | B |     | C | | A |     | B |     | C |
  16. Posterior lumbar interbody fusion (PLIF) | A |     | B |     | C | | A |     | B |     | C |
  17. Shunt procedure/VP, VA/LP | A |     | B |     | C | | A |     | B |     | C |
  18. Spine fusion - list systems you have used Enter:____________  _____________
  19. Ulnar nerve transfer | A |     | B |     | C | | A |     | B |     | C |
  20. Ventriculography procedure/ventriculoscopy | A |     | B |     | C | | A |     | B |     | C |
  21. Ventriculostomy | A |     | B |     | C | | A |     | B |     | C |

F. OPHTHALMOLOGY SCRUB CIRCULATE
  1. Cataract extraction with IOL | A |     | B |     | C | | A |     | B |     | C |
  2. Corneal transplant | A |     | B |     | C | | A |     | B |     | C |
  3. Dacryocystectomy | A |     | B |     | C | | A |     | B |     | C |
  4. Dacryocystorhinostomy | A |     | B |     | C | | A |     | B |     | C |
  5. Iridectomy | A |     | B |     | C | | A |     | B |     | C |
  6. Lid and muscle procedures | A |     | B |     | C | | A |     | B |     | C |
  7. Orbital implant | A |     | B |     | C | | A |     | B |     | C |
  8. Phaco emulsification | A |     | B |     | C | | A |     | B |     | C |
  9. Pterygium repair | A |     | B |     | C | | A |     | B |     | C |
  10. Recession resection | A |     | B |     | C | | A |     | B |     | C |
  11. Repair orbital blowout fracture | A |     | B |     | C | | A |     | B |     | C |
  12. Scleral buckle | A |     | B |     | C | | A |     | B |     | C |
  13. Vitrectomy | A |     | B |     | C | | A |     | B |     | C |

G. ORAL SCRUB CIRCULATE
  1. Closed reduction facial fractures/wiring | A |     | B |     | C | | A |     | B |     | C |
  2. Excision odontoma | A |     | B |     | C | | A |     | B |     | C |
  3. Extraction of deciduous teeth | A |     | B |     | C | | A |     | B |     | C |
  4. Extraction of impacted molars | A |     | B |     | C | | A |     | B |     | C |
  5. Fractured jaws, mandibular and zagomatic | A |     | B |     | C | | A |     | B |     | C |
  6. LeFort osteotomies | A |     | B |     | C | | A |     | B |     | C |
  7. Maxillary procedure with graft | A |     | B |     | C | | A |     | B |     | C |
  8. Pediatric dentistry | A |     | B |     | C | | A |     | B |     | C |
  9. Sagittal osteotomy | A |     | B |     | C | | A |     | B |     | C |
  10. Temporomandibular joint (TMJ) with arthroplasty | A |     | B |     | C | | A |     | B |     | C |
  11. TMJ exploration | A |     | B |     | C | | A |     | B |     | C |

H. ORTHOPEDICS SCRUB CIRCULATE
  1. Acetabular/pelvic ORIF | A |     | B |     | C | | A |     | B |     | C |
  2. Achilles tendon repair | A |     | B |     | C | | A |     | B |     | C |
  3. Amputation - leg, arm | A |     | B |     | C | | A |     | B |     | C |
  4. Anterior cruciate ligament repair | A |     | B |     | C | | A |     | B |     | C |
  5. Application of external fixators    
    a. Extremities | A |     | B |     | C | | A |     | B |     | C |
    b. Pelvis | A |     | B |     | C | | A |     | B |     | C |
  6. Application of halo traction | A |     | B |     | C | | A |     | B |     | C |
  7. Arthroscopy    
    a. Ankle | A |     | B |     | C | | A |     | B |     | C |
    b. Elbow | A |     | B |     | C | | A |     | B |     | C |
    c. Knee | A |     | B |     | C | | A |     | B |     | C |
    d. Shoulder | A |     | B |     | C | | A |     | B |     | C |
  8. Arthrotomy | A |     | B |     | C | | A |     | B |     | C |
  9. Bipolar/unipolar hips | A |     | B |     | C | | A |     | B |     | C |
  10. Bunionectomy | A |     | B |     | C | | A |     | B |     | C |
  11. Calcaneal reconstruction | A |     | B |     | C | | A |     | B |     | C |
  12. Capsulorrhaphy | A |     | B |     | C | | A |     | B |     | C |
  13. Carpal tunnel release | A |     | B |     | C | | A |     | B |     | C |
  14. Closed reduction fracture | A |     | B |     | C | | A |     | B |     | C |
  15. Hand surgery with implants | A |     | B |     | C | | A |     | B |     | C |
  16. Harrington rod instrumentation and/or Dwyer procedure | A |     | B |     | C | | A |     | B |     | C |
  17. Heel cord lengthening | A |     | B |     | C | | A |     | B |     | C |
  18. Hip compression nails & lag screws
    a. Jewett | A |     | B |     | C | | A |     | B |     | C |
    b. Kuntscher rod | A |     | B |     | C | | A |     | B |     | C |
    c. Lottes | A |     | B |     | C | | A |     | B |     | C |
    d. Rush | A |     | B |     | C | | A |     | B |     | C |
    e. Schneider | A |     | B |     | C | | A |     | B |     | C |
    f. Zimmer | A |     | B |     | C | | A |     | B |     | C |
    g. Others - list Enter:__________  ____________
  19. Iliac crest bone graft | A |     | B |     | C | | A |     | B |     | C |
  20. Insertion Austin Moor hip prosthesis | A |     | B |     | C | | A |     | B |     | C |
  21. Intramedullary rods    
    a. Extraction | A |     | B |     | C | | A |     | B |     | C |
    b. Femoral | A |     | B |     | C | | A |     | B |     | C |
    c. Humeral | A |     | B |     | C | | A |     | B |     | C |
    d. Insertion | A |     | B |     | C | | A |     | B |     | C |
    e. Supracondylar | A |     | B |     | C | | A |     | B |     | C |
    f. Tibial | A |     | B |     | C | | A |     | B |     | C |
  22. Laminectomy | A |     | B |     | C | | A |     | B |     | C |
  23. Olecranon bursa, excision of | A |     | B |     | C | | A |     | B |     | C |
  24. Open reduction of fracture, internal fixation with compression set | A |     | B |     | C | | A |     | B |     | C |
  25. Patellectomy | A |     | B |     | C | | A |     | B |     | C |
  26. Putti Platt/Bankart procedure/rotator cuff repair | A |     | B |     | C | | A |     | B |     | C |
  27. Reduction with compression sets | A |     | B |     | C | | A |     | B |     | C |
  28. Reimplantation of digits | A |     | B |     | C | | A |     | B |     | C |
  29. Repair hammer toes | A |     | B |     | C | | A |     | B |     | C |
  30. Sacro-iliac (SI) joint screws | A |     | B |     | C | | A |     | B |     | C |
  31. Sharrard procedure | A |     | B |     | C | | A |     | B |     | C |
  32. Spica cast, application of | A |     | B |     | C | | A |     | B |     | C |
  33. Spinal fusion | A |     | B |     | C | | A |     | B |     | C |
  34. Tendon transplants (hand and foot) | A |     | B |     | C | | A |     | B |     | C |
  35. Total joint replacements/revisions
    a. Total hip | A |     | B |     | C | | A |     | B |     | C |
    b. Total knee | A |     | B |     | C | | A |     | B |     | C |
    c. Total shoulder | A |     | B |     | C | | A |     | B |     | C |

I. PLASTICS SCRUB CIRCULATE
  1. Abdominal lipectomy | A |     | B |     | C | | A |     | B |     | C |
  2. Blepharoplasty | A |     | B |     | C | | A |     | B |     | C |
  3. Face lift | A |     | B |     | C | | A |     | B |     | C |
  4. Mammoplasty
    a. Augmentation | A |     | B |     | C | | A |     | B |     | C |
    b. Reduction | A |     | B |     | C | | A |     | B |     | C |
    c. Tramflaps with reconstructive mammoplasty | A |     | B |     | C | | A |     | B |     | C |
  5. Mentoplasty | A |     | B |     | C | | A |     | B |     | C |
  6. Otoplasty | A |     | B |     | C | | A |     | B |     | C |
  7. Pedicle grafts | A |     | B |     | C | | A |     | B |     | C |
  8. Scar revisions | A |     | B |     | C | | A |     | B |     | C |
  9. Split thickness skin grafting | A |     | B |     | C | | A |     | B |     | C |
  10. Tissue expanders | A |     | B |     | C | | A |     | B |     | C |

J. THORACIC & OPEN HEART SCRUB CIRCULATE
  1. Cervical rib excision | A |     | B |     | C | | A |     | B |     | C |
  2. Chamberlain procedure | A |     | B |     | C | | A |     | B |     | C |
  3. Closed thoracotomy | A |     | B |     | C | | A |     | B |     | C |
  4. Correction pectus excavatum | A |     | B |     | C | | A |     | B |     | C |
  5. Esophagectomy | A |     | B |     | C | | A |     | B |     | C |
  6. Heller procedure | A |     | B |     | C | | A |     | B |     | C |
  7. Mitral commissurotomy | A |     | B |     | C | | A |     | B |     | C |
  8. Open heart procedures
    a. Mitral or aortic valve replacement | A |     | B |     | C | | A |     | B |     | C |
    b. Patent ductus arteriosus | A |     | B |     | C | | A |     | B |     | C |
    c. Septal defect repairs | A |     | B |     | C | | A |     | B |     | C |
    d. Tetrology of Fallot | A |     | B |     | C | | A |     | B |     | C |
  9. Pacemaker implantation-endocardial | A |     | B |     | C | | A |     | B |     | C |
  10. Pacemaker implantation-myocardial | A |     | B |     | C | | A |     | B |     | C |
  11. Pericardiectomy | A |     | B |     | C | | A |     | B |     | C |
  12. Resection coarctation aorta | A |     | B |     | C | | A |     | B |     | C |
  13. Rib resection | A |     | B |     | C | | A |     | B |     | C |
  14. Thoracoplasty | A |     | B |     | C | | A |     | B |     | C |
  15. Tracheal resection | A |     | B |     | C | | A |     | B |     | C |
  16. Transthoracic diaphragmatic herniorrhaphy | A |     | B |     | C | | A |     | B |     | C |

K. TRANSPLANT SCRUB CIRCULATE
  1. Bone | A |     | B |     | C | | A |     | B |     | C |
  2. Bone marrow | A |     | B |     | C | | A |     | B |     | C |
  3. Corneal | A |     | B |     | C | | A |     | B |     | C |
  4. Harvesting | A |     | B |     | C | | A |     | B |     | C |
  5. Heart | A |     | B |     | C | | A |     | B |     | C |
  6. Kidney | A |     | B |     | C | | A |     | B |     | C |
  7. Liver | A |     | B |     | C | | A |     | B |     | C |
  8. Lung | A |     | B |     | C | | A |     | B |     | C |
  9. Multi-organ | A |     | B |     | C | | A |     | B |     | C |
  10. Pancreas | A |     | B |     | C | | A |     | B |     | C |
  11. Skin | A |     | B |     | C | | A |     | B |     | C |

L. TRAUMA SCRUB CIRCULATE
  1. Burns | A |     | B |     | C | | A |     | B |     | C |
  2. Gunshot/stab wounds
    a. Abdomen | A |     | B |     | C | | A |     | B |     | C |
    b. Chest | A |     | B |     | C | | A |     | B |     | C |
    c. Head | A |     | B |     | C | | A |     | B |     | C |
  3. Motor vehicle accidents (multiple injuries) | A |     | B |     | C | | A |     | B |     | C |
  4. Traumatic amputations | A |     | B |     | C | | A |     | B |     | C |

M. UROLOGY SCRUB CIRCULATE
  1. Adult circumcision | A |     | B |     | C | | A |     | B |     | C |
  2. Cystectomy | A |     | B |     | C | | A |     | B |     | C |
  3. Cystoscopy/ureteroscopy | A |     | B |     | C | | A |     | B |     | C |
  4. Hypospadias repair | A |     | B |     | C | | A |     | B |     | C |
  5. Implants: penile, testicular | A |     | B |     | C | | A |     | B |     | C |
  6. Lithotripsy | A |     | B |     | C | | A |     | B |     | C |
  7. Nephrectomy | A |     | B |     | C | | A |     | B |     | C |
  8. Nephrolithotomy | A |     | B |     | C | | A |     | B |     | C |
  9. Orchiopexy | A |     | B |     | C | | A |     | B |     | C |
  10. Prostatectomy
    a. Perineal | A |     | B |     | C | | A |     | B |     | C |
    b. Supra-pubic | A |     | B |     | C | | A |     | B |     | C |
  11. Pyeloplasty | A |     | B |     | C | | A |     | B |     | C |
  12. Radical node dissection | A |     | B |     | C | | A |     | B |     | C |
  13. Scott incontinence device | A |     | B |     | C | | A |     | B |     | C |
  14. TURP | A |     | B |     | C | | A |     | B |     | C |
  15. Ureterolithotomy | A |     | B |     | C | | A |     | B |     | C |
  16. Vasectomy | A |     | B |     | C | | A |     | B |     | C |
  17. Vasovasostomy | A |     | B |     | C | | A |     | B |     | C |
  18. Waterhouse procedure | A |     | B |     | C | | A |     | B |     | C |

N. VASCULAR SCRUB CIRCULATE
  1. A-V access graft | A |     | B |     | C | | A |     | B |     | C |
  2. Aortic aneurysm with graft replacement | A |     | B |     | C | | A |     | B |     | C |
  3. Endarterectomy/carotid - femoral | A |     | B |     | C | | A |     | B |     | C |
  4. Peripheral vascular bypass procedures | A |     | B |     | C | | A |     | B |     | C |
  5. Resection carotid aneurysm with graft | A |     | B |     | C | | A |     | B |     | C |
  6. Thrombectomy/embolectomy | A |     | B |     | C | | A |     | B |     | C |
  7. Vena cava filter/umbrella | A |     | B |     | C | | A |     | B |     | C |
  8. Vena cava ligation | A |     | B |     | C | | A |     | B |     | C |

O. ANESTHESIA
  1. Assist with intubation | A |     | B |     | C |
  2. Conscious sedation - administration and monitoring | A |     | B |     | C |
  3. Management of malignant hyperthermia crisis | A |     | B |     | C |

P. EQUIPMENT
  1. Argon beam coagulator | A |     | B |     | C |
  2. Bair Hugger | A |     | B |     | C |
  3. Blood/fluid warmer | A |     | B |     | C |
  4. Camera/video systems
    a. Camera controller | A |     | B |     | C |
    b. Light source | A |     | B |     | C |
    c. Printers | A |     | B |     | C |
    d. VCRs | A |     | B |     | C |
  5. Cardiac monitor and pacemaker | A |     | B |     | C |
  6. Cell saver | A |     | B |     | C |
  7. Cidex soak | A |     | B |     | C |
  8. Cry-ophthalmic unit | A |     | B |     | C |
  9. Defibrillator/pacer | A |     | B |     | C |
  10. Dermatome
    a. Brown | A |     | B |     | C |
    b. Padgett | A |     | B |     | C |
    c. Zimmer | A |     | B |     | C |
  11. Disposable grounding pads | A |     | B |     | C |
  12. Drills
    a. 3-M Maxi driver | A |     | B |     | C |
    b. Codman craniotome | A |     | B |     | C |
    c. Hall air driver | A |     | B |     | C |
    d. Hall dental | A |     | B |     | C |
    e. Hall neurotome | A |     | B |     | C |
    f. Midax Rex/Anspach | A |     | B |     | C |
    g. Minidriver | A |     | B |     | C |
    h. Stryker drills  
      (1) Large battery Stryker | A |     | B |     | C |
      (2) Small battery Stryker | A |     | B |     | C |
    i. Surgairtome | A |     | B |     | C |
    j. Synthes A-O Drill | A |     | B |     | C |
  13. Electrosurgical unit | A |     | B |     | C |
  14. Emerson thoracic pump | A |     | B |     | C |
  15. Ethylene oxide sterilizer - AMSCO | A |     | B |     | C |
  16. Eye magnet | A |     | B |     | C |
  17. Fiber optic luminator - list types Enter:__________
  18. Flash autoclave - AMSCO | A |     | B |     | C |
  19. Fracture tables
    a. Chick table/Marquet table | A |     | B |     | C |
    b. Jackson table | A |     | B |     | C |
    c. Rush table/Skytron table | A |     | B |     | C |
  20. Hypo/hyperthermia unit | A |     | B |     | C |
  21. Intestinal stapling devices
    a. EEA | A |     | B |     | C |
    b. GIA | A |     | B |     | C |
    c. LDS | A |     | B |     | C |
    d. TA | A |     | B |     | C |
  22. Kreiselman resuscitator | A |     | B |     | C |
  23. Laser
    a. CO2 | A |     | B |     | C |
    b. Eye | A |     | B |     | C |
    c. Yag | A |     | B |     | C |
    d. Other Enter:__________
  24. Mesh graft | A |     | B |     | C |
  25. Microscopes, list type Enter:__________
  26. Nerve stimulator | A |     | B |     | C |
  27. Nitrous oxide bank | A |     | B |     | C |
  28. Ohio suction units | A |     | B |     | C |
  29. Orthopedic arm board with drain | A |     | B |     | C |
  30. Pleurevac disposable chest drainage | A |     | B |     | C |
  31. Pneumatic tourniquet | A |     | B |     | C |
  32. Sterad machine | A |     | B |     | C |
  33. Steri-vac aeration cabinet, 3-M, portable | A |     | B |     | C |
  34. Steris unit | A |     | B |     | C |
  35. Suction unit, disposable | A |     | B |     | C |
  36. Tele-thermometer | A |     | B |     | C |
  37. Ultrasonic cleaner - AMSCO | A |     | B |     | C |
  38. Vac-pac positioner | A |     | B |     | C |
  39. Vacuum curettage | A |     | B |     | C |
  40. Washer sanitizer - AMSCO | A |     | B |     | C |
  41. Washer sterilizer - AMSCO | A |     | B |     | C |

Q. PHLEBOTOMY/IV THERAPY
  1. Equipment & procedures  
    a. Administration of blood/blood products  
      (1) Packed red blood cells | A |     | B |     | C |
      (2) Whole blood | A |     | B |     | C |
    b. Assist with IA/IV therapy
      (1) Insertion of A-lines | A |     | B |     | C |
      (2) Insertion of CVP - jugular/subclavian | A |     | B |     | C |
      (3) Insertion of Swan-Ganz | A |     | B |     | C |
    c. Drawing blood from central line | A |     | B |     | C |
    d. Drawing venous blood | A |     | B |     | C |
    e. Starting IVs  
      (1) Angiocath | A |     | B |     | C |

AGE SPECIFIC PRACTICE CRITERIA
Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.
A. Newborn/Neonate (birth - 30 days) F. Adolescents (12 - 18 years)
B. Infant (30 days - 1 year) G. Young adults (18 - 39 years)
C. Toddler (1 - 3 years) H. Middle adults (39 - 64 years)
D. Preschooler (3 - 5 years) I. Older adults (64+)
E. School age children (5 - 12 years)
EXPERIENCE WITH AGE GROUPS: A B C D E F G H I
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Can ensure a safe environment reflecting specific needs of various age groups.

My experience is primarily in: (Please indicate number of years.)
Total years OR nursing: ___ year(s)
Endoscopy ___ year(s) Ortho ___ year(s)
ENT ___ year(s) Plastics ___ year(s)
General ___ year(s) Thoracic/open heart ___ year(s)
GYN ___ year(s Transplant ___ year(s)
Neuro ___ year(s) Trauma ___ year(s)
Ophthalmology ___ year(s) Urology ___ year(s)
Oral ___ year(s) Vascular ___ year(s)
Certification:
Please check the boxes below and indicate the expiration date for each certificate that you have. If you do not know the exact date, please use the last date of the specific month (e.g., 08/31/2003).

BCLS   ________ (mm/dd/yyyy)
CNOR   ________ (mm/dd/yyyy)
ACLS ________ (mm/dd/yyyy)
CRNFA   ________ (mm/dd/yyyy)
Other (type): ________________ ________ (mm/dd/yyyy)
Computerized charting system: ________________ ________ (mm/dd/yyyy)
Medication administration system: ________________ ________ (mm/dd/yyyy)

The information I have given is true and accurate to the best of my knowledge. 
 

Signature: ______________________________ Date: _______________