LAST 4 OF SSN      
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) Universal Precautions 1 2 3 4  
Working with patients in isolation  
Working with patients in restraints  
Patient/Family teaching  
Patient Identification  
Specialty beds  
End of life care/palliative care  
Knowledge of "Do Not Use Abbreviations"  
Do you have charge/supervisor experience?  
Knowledge of current Joint Commission National Patient Safety Goals  
Knowledge/familiarity with HCAHPS scores  
Rating Stars (Click) Acute Care/ Hospital 1 2 3 4  
Durable Medical Equipment ( DME)  
Managed Care  
SNF/ Long Term Care  
Home Health  
Physician Office  
Rating Stars (Click) Understanding of health care economics and health care policies as it applies to delivery of patient care 1 2 3 4  
Concepts of capital budgeting  
Department/unit budgeting  
Recruitment techniques  
Interviewing techniques  
Labor Laws pertaining to hiring  
Orientation of new employees  
Knowledge of quality improvement/performance improvement tools  
Patient Safety  
Workplace safety  
Promotion of interdepartmental communication  
Performance management  
Staff Development  
Coaching and mentoring  
Project management  
Business development  
Developing Strategic plans  
Developing operational plans  
Cultural competence  
Personal growth and development  
Ethical behavior and practice  
Professional association involvement  
Conflict Management  
Team dynamics  
TJC Standards  
OSHA Standards  
Risk Management/Service Utilization  
Local Department of Health  
State Department of Health  
Sitter Services  
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)