Your Contact Information

GENERAL SKILLS EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Advanced directives123
Cultural diversity123
Patient teaching123
Restrictive devices (restraints)123
Ambulatory cuffs123
End of life care/palliative care123
Correctional admission & discharge123
Correctional alarm systems123
Automated Medication Dispensing System, Pyxis, Omnicell, or other123
Diabetes mellitus123
Blood Glucose Monitoring (BGM)123
Insulin administration123
National Patient Safety Goals123
Accurate patient/inmate identification123
Effective communication123
Interpretation & communication of lab values123
Medication administration123
Labeling: obtain lab specimens123
Anticoagulation therapy123
Pain assessment & management123
Infection control123
Universal precautions123
Isolation123
Assist with treatment procedures123
Wound care123
IV THERAPY *
Starting & maintaining peripheral IVs123
Venous blood draw123
CARDIAC MONITORING & EMERGENCY CARE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *
Cardiac monitors123
Interpretation of rhythm strips123
Obtains 12 lead EKG123
Treatment of dysrythmias123
Cardiac arrest/CPR123
O2 therapy & delivery123
Pulse oximetry123
Use of doppler123
Assessment of heart sounds123
Vascular assessment123
Awareness of HCAHPS123
CARE OF THE PATIENT WITH
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Angina123
CHF123
Post MI123
RESPIRATORY EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Assessment of breath sounds123
Establishing an airway123
Ambuing techniques123
Suctioning123
CARE OF PATIENT WITH
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
COPD123
Pneumocystis123
Pneumonia123
Emphysema123
Asthma123
Tuberculosis123
USE & ADMINISTRATION OF THE FOLLOWING
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Bronchodilators123
Steroids123
Expectorants123
GYNECOLOGY EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Gyn exam/pap123
Self breast exam123
Ectopic pregnancy123
Pelvic inflammatory disease123
Endometriosis123
NEUROLOGY EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Neurological assessment123
Glasgow coma scale123
Seizure precautions123
Assist with lumbar puncture123
CARE OF PATIENT WITH
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Post CVA123
TIA123
Seizure activity123
Head & spinal cord injury/trauma123
Cranial hemorrhage123
Delirium tremors123
Neuromuscular diseases123
USE & ADMINISTRATION OF THE FOLLOWING
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Antiepileptics123
Steroids123
PSYCHIATRIC DISORDERS EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Psych assessment123
Suicide risk assessment123
Suicide precautions123
Major depression123
Bipolar disorder (manic-depressive illness)123
Anxiety disorders123
Post Traumatic Stress Disorder (PTSD)123
Psychotic disorders123
Schizophrenia123
Personality disorders123
Antisocial123
Passive / aggressive123
Paranoia123
Schizotypal personality disorder123
Eating disorders123
Anorexia nervosa123
Bulemia nervosa123
Pica123
CRISIS MANAGEMENT EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Homicide123
Suicide123
Rape123
Violent individual123
SUBSTANCE USE/ABUSE EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Alcoholism123
Alcohol withdrawal syndrome123
Delirium Tremens (DTs)123
Wernicke-Korsakoff syndrome123
Drug use / abuse123
Hallucinogenics123
Opiates (heroin, morphine, oxycodone, codeine)123
Stimulants (cocaine / amphetamines)123
Benzodiaepams123
Drug withdrawal / detoxification123
CARE OF PATIENT WITH
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Delusions123
Hallucinations123
Gastrointestinal Experience123
GI assessment123
NG tube insertion & management123
Enterostomal care123
CARE OF PATIENT WITH
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Pancreatitis123
Hepatitis123
G.I. bleed123
Esophageal bleeding123
Bowel obstruction123
USE & ADMINISTRATION OF THE FOLLOWING
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Anticholinergics (antispas, Bentyl or Robinul)123
Cathartics123
GENITOURINARY/RENAL EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
AV shunt/fistula123
Catheter insertion123
GU irrigations123
ORTHOPEDIC EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Splints123
Cast care123
Cast removal123
Ortho trauma123
OTHER EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Staple/suture removal123
Oncology123
Chemotherapy123
Leadership skills (team leader or charge nurse)123
Supervision of unlicensed assistive personnel123
Post mortem care123
Training in over familiarization with inmates123
Training in potential/actual weapon recognition123
AGE SPECIFIC COMPETENCIES EXPERIENCE
Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently
 *
Newborn / neonate (birth-30 days)123
Infant (31 days-1 year)123
Toddler (ages 2-3 years)123
Preschool (ages 4-5 years)123
School age (ages 6-12 years)123
Adolescent (ages 13-21 years)123
Young adult (ages 22-39 years)123
Adult (ages 40-64 years)123
Older adult (ages 65-79 years)123
Elderly (ages 80+ years)123
ATTESTATION *