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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

Work Settings Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Inpatient hospital
Level 1 trauma center
Outpatient setting
General Skills Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Awareness of HCAHPS
Patient/family teaching
Restrictive devices (restraints)
Lift/transfer devices
Patient positioning
National Patient Safety Goals
Accurate patient identification
Effective communication
Infection control
Universal precautions
Care of the patient in isolation
Medication administration on sterile field
Labeling (medications & specimens) on sterile field
Time out protocol
General Surgery Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Abdominal perineal resection
Adrenalectomy
Bowel resection
Cholecystectomy/cholangiogram
Colostomy/ileostomy
Gastrectomy
Herniorrhaphy-femoral/inguinal
Hiatal herniorrhaphy transabdominal
Pancreatectomy
Organ procurement
Radical mastectomy
Saphenous vein ligation/stripping
Splenectomy
Thyroidectomy
Vagotomy
Breast biopsy
Mastectomy
Common bile duct explorations
Open appendectomy
Jejunostomy tube replacement
Liver biopsy
Excision of lipoma
Parathyroidectomy
Parathyroidectomy with transplant
Gynecology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Caesarean section
Dilation & curettage
Hysterectomy - vaginal
Hysterectomy - abdominal
Radium insertion
Shirodkar procedure
Termination of pregnancy
Tubal ligation
Vaginectomy
Vaginal anterior repair surgery
Vaginal posterior repair surgery
Salpingo-oopherectomy
Endoscopic Procedures Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Bronchoscopy
Endo/colonoscopy
Culdoscopy
Cystoscopy
Esophagoscopy
Gastroscopy
Hysteroscopy
Laparoscopic Procedures
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Appendectomy
Cholecystectomy
Colon resection
Hernia repair
Salpingo-oophorectomy
Tubal ligation
Vaginal hysterectomy
Laryngoscopy
Mediastinoscopy
Pelviscopy
Sigmoidoscopy
Thoracoscopy
Urology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Circumcision
Cystoscopy/ureteroscopy
Cystectomy
Hypospadias repair
Implants
Lithotripsy
Nephrectomy
Orchiectomy
Prostatectomy
Ureterolithotomy
TURP
Vasectomy
Implants - penile
Uteroplasty
Transurethral Resection of Bladder Tumor (TURBT)
Testicular tortion
Orthopedic Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Achilles tendon repair
Amputation
Arthroscopy/arthrotomy
Closed pinning & reduction of extremities
External compression devices
Hip compression nails & lag screws
Total joint replacement - knee, hip, shoulder
Spica cast
ORIF - shoulder, hip, humerus
Repair of dislocation
Patellectomy
Tendon implants & reanastomosis
External fixator
ORIF - ankle
ORIF - radius/ulna
Neurology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
A-V malformation
Laparoscopic spine procedures
Burr holes for subdural hematoma
Carotid ligation
Cervical sympathectomy
Cranioplasty
Craniotomy
Discectomy/laminectomy
Halo traction application
Insertion of nerve stimulator devices
Myelomeningocele repair
Shunt procedure VP/ VA/LP
Spinal fusions
Ventriculostomy
Kyphoplasty
Spinal cord stimulator insertion
Cervical laminectomy
Lumbar laminectomy
Spinal fusion - cervical
Spinal fusion - lumbar
Panniculectomy
Plastics Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Abdominal lipectomy
Blepharoplasty
Face lift
Mammoplasty
Augmentation
Reduction
Reconstructive
Liposuction
Otoplasty
Scar revisions
Skin grafting
Opthamology Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Cataract extraction
IOL implants
Corneal transplant
Orbital implant
Enucleation
Repair orbital blowout fracture
Repair of retinal detachment
Scleral buckle
Ear, Nose & Throat Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Caldwell-luc
Cleft lip/palate repair
Laryngectomy
Radial neck disection/resection
Tonsillectomy & adenoidectomy
Mandibulectomy
Mastoidectomy
Rhinoplasty/septoplasty
Sinusotomy
Tracheostomy
Vascular Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Angiography
A-V access graft
Aortic aneurysm: abdominal
Endarterectomy: carotid
Peripheral vascular bypass procedures
Thrombectomy
Embolectomy
Vena cava ligation
Thoracic/Cardiovascular Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Aortic femoral bypass graft
Femoral popliteal bypass
Pacemaker implantation/explantation
Care of patients with pacemakers
Care of patients with IABP
Septal defects, ASV, VSD
Coronary artery bypass graft
Valve replacement
Aortic aneurysm: thoracic
Thoracotomy
Lobectomy
Rib resection
Endoscopic vein harvesting
Off pump bypass
Transplant Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Bone
Bone marrow
Corneal
Harvesting
Heart/lung
Kidney
Liver
Multi organ
Pancreas
Skin
Trauma Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Burns
Gunshot/stab wound
Motor vehicle accidents
Traumatic amputations
Equipment Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Camera/video systems
Cell saver
Cidex soak
Cryo-ophthalmic unit
CUSA
Drills & saws
Electrosurgical unit
Fiber optic laminator
Cavitron
Autoclave
Fracture tables
Stapling devices
Mesh graft/dermatone
Microscopes
Nitrogen tank
Pneumatic tourniquet
Steris unit
Pulsevac irrigation
Autotransfusion systems
Laser equipment
Care of scopes & fiberoptic equipment
Venodyne robotics (DaVinci)
Age Specific Competencies Experience
(1) Limited or no experience
(2) Experienced, but may need review or supervision
(3) Able to function independently *
 123
Newborn/neonate (birth-30 days)
Infant (31 days-1 year)
Toddler (ages 2-3 years)
Preschool (ages 4-5 years)
School age (ages 6-12 years)
Adolescent (ages 13-21 years)
Young adult (ages 22-39 years)
Adult (ages 40-64 years)
Older adult (ages 65-79 years)
Elderly (ages 80+ years)
ATTESTATION *