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) Knowledge of Assessment Process 1 2 3 4  
Psychosocial assessment (social history, living situation, career, hobbies, support systems, decision making, communication difficulties, flexibility, prolonged mental illness / emotional Problems, lack of community / caregiver support, family discord, ability to deal with loss)  
Rating Stars (Click) Communication Abilities 1 2 3 4  
Develop and maintain communication with people on complex matters, issues and ideas, and/or in complex situations  
Rating Stars (Click) Personal and People Development 1 2 3 4  
Develop oneself and contribute to the development of others  
Rating Stars (Click) Quality Improvement & Service 1 2 3 4  
Contribute to the improvement of services & maintain quality in own work and encourage others to do so  
Rating Stars (Click) Health Protection & Well Being 1 2 3 4  
Implement aspects of a protection plan and review its effectiveness  
High risk intervention / patient vulnerability or safety risk  
Monitor and maintain health, safety and security of self and others  
Provide crisis intervention  
Rating Stars (Click) Care Planning 1 2 3 4  
Assess complex health and well being needs and develop, monitor and review care plans to meet those needs  
Rating Stars (Click) Knowledge and InformationResources 1 2 3 4  
Organize knowledge and information resources and provide information to meet needs  
Demonstrates respect for patient/family confidentiality  
Documentation Skills (accurate, timely, complete and legible)  
Counseling for long range planning and decision making  
Rating Stars (Click) Equality and Diversity 1 2 3 4  
Promote equality and value diversity  
Rating Stars (Click) Experience in all or any of the following: 1 2 3 4  
Medical Social Work  
School Social Work  
Clinical Social Work  
Social Work-Admin/management  
Social work-case manager  
International Social Work  
Social Work-Children & Families  
Social Work in Acute Psychiatric Hospital  
Forensic Social Work  
Employment/Occupational Social Work  
Social Work- Community Organizer  
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)