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