LAST 4 OF SSN      
I hereby certify that ALL information I have provided to FILL IN THE BLANK 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) Surveillance 1 2 3 4  
 Performs targeted surveillance  
Outbreak investigations  
Collaboration  with Infection Control Committee  
Collaboration with Hospital Epidemiologist  
Performance improvement projects related in communicable diseases  
Collects, monitors, and maintains data using  facility HER  
Utilize Center for Disease Control (CDC)  
Infection criteria  
Documentation and investigation techniques  
Rounds of hospital units  
Case definition, and other related patient care issues  
Monitor  infection control practices  
Nosocomial infections  or AHIs, MRSAs  
Health care workers exposures  
Tracing the possible sources of infection or transmission of microorganisms  
Rating Stars (Click) Identification of Problems 1 2 3 4  
Regularly meet with the hospital Epidemiologist  
Risk  reduction among patients, facility staff, volunteers, students, and visitors  
Understand the transmission and break of infections  
Identification of epidemiologically important issues for Infection Control Committee  
Rating Stars (Click) Hospital Epidemiologist,  and Administration 1 2 3 4  
Design COA  including Surveillance, Outbreak Investigations, and Performance Improvement Projects  
Communicable diseases reporting as required by the state and the local health authority  
Compliance with federal and state laws regarding  medical wastes, chemicals in the workplace, infectious disease exposures  
OSHA NIOSH standards  
Blood borne pathogens and respiratory pathogens  
Chart review  
Rating Stars (Click) Policies and Procedures 1 2 3 4  
Infection Control policies associated with infection  
Staff practices associated with infection contol  
Professional guidelines (CDC, APIC, etc.)  
The Joint Commission guidelines on infection Control  
Infection Control Plan to reflect and meet any required changes  
Rating Stars (Click) Coordination 1 2 3 4  
Acts as department liaison for Infection Control Department  
Act as consultant for the facility Infection Control activities  
Interdepartment and personnel coordination on risk  reduction, transmission and improved infection control practices  
Provide coordinated services to patients for the improvement of overall  
Patient care  
Rating Stars (Click) Education 1 2 3 4  
In-services of all and current employees  on Infection Control  
Orientation programs of new employees on Infection Control  
Infection Control techniques and Policies and Procedures  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)