RN Occupational and Employee Health Skills Checklist
  RN Occupational and Employee Health Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

 
       
Rating Stars (Click) TRAUMA 1 2 3 4  
Care of Patient with:  
Minor Trauma  
Major Trauma  
MAST Suit  
Rating Stars (Click) BURNS 1 2 3 4  
Care of Patient with:  
First Degree  
Second Degree  
Third Degree  
Electrocution  
Hazardous Materials Exposure  
Rating Stars (Click) LACERATIONS 1 2 3 4  
Care of Patient with:  
Assessment  
Cleansing  
Steri-Strips  
Dressing  
Rating Stars (Click) SPRAIN/STRAIN 1 2 3 4  
Assessment  
Carpal Tunnel  
Tendonitis  
Epicondylitis  
Rating Stars (Click) PHYSICALS 1 2 3 4  
Safety  
Return to Work  
Respirator  
Vital Signs  
Height/Weight  
Blood Draw  
Medical Referral Form  
Medical Certification Form  
Medical History Questionnaire  
Potassium Iodine Assessment  
Rating Stars (Click) RESTRICTIONS 1 2 3 4  
Temporary Restrictions  
Permanent Restrictions  
Pulmonary Function  
Audiometry  
Vision Testing  
X-ray  
Urine Testing  
Drug Testing  
Breathalyzer  
Rating Stars (Click) IMMUNIZATIONS 1 2 3 4  
Havrix (Hepatitis A)  
Influenza Vaccine  
Meningitis Vaccine  
Tetanus & Diphtheria  
Oral Typhoid Vaccine  
Polio Vaccine  
Hepatitis B Vaccine  
Japanese Encephalitis B  
Rabies Vaccine  
Typhim (Injectable Type)  
Yellow Fever Vaccine  
Rating Stars (Click) Age Specific Criteria 1 2 3 4  
Newborn/Neonate (birth-30 days)  
Infant (30 days - 1 year)  
Toddler (1-3 years)  
Preschooler (3-5 years)  
School Age Children (5-12 years)  
Adolescents (12-18 years)  
Adolescents (12-18 years)  
Young Adults (18-39 years)  
Middle Adults (39-64 years)  
Older Adults (64+)