Physician Assistant Self Assessment

Physician Assistant Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional. 1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Print Name Last 4 Digits of SS# Date Areas Worked Emergency 0 1 2 3 4 5 Urgent Care 0 1 2 3 4 5 Private Practice 0 1 2 3 4 5 HMO 0 1 2 3 4 5 MD Office 0 1 2 3 4 5 Schools 0 1 2 3 4 5 Health Department 0 1 2 3 4 5 Ambulatory Clinic 0 1 2 3 4 5 Rural Health Clinic 0 1 2 3 4 5 Psychiatric Facility 0 1 2 3 4 5 Correctional Facility 0 1 2 3 4 5 Mobile Medical Unit 0 1 2 3 4 5 Corporate Worksite 0 1 2 3 4 5 Occupational Health 0 1 2 3 4 5 Rehabilitation 0 1 2 3 4 5 Nursing Home/ Long-term Care Facility 0 1 2 3 4 5 Women's Health Clinic 0 1 2 3 4 5 Government Health Agency 0 1 2 3 4 5 Hospice/Palliative Care 0 1 2 3 4 5 With Diabetes 0 1 2 3 4 5 Contractures 0 1 2 3 4 5 Bedridden residents 0 1 2 3 4 5 Splinting of extremities 0 1 2 3 4 5 Local infiltration 0 1 2 3 4 5 Comprehensive physical assessment 0 1 2 3 4 5 Acute disease condition 0 1 2 3 4 5 Differential diagnosis 0 1 2 3 4 5 Order, may perform, & interpret screening & diagnostic test 0 1 2 3 4 5 Central line management 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 1 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Disorders Emergencies Anaphylaxis 0 1 2 3 4 5 Cardiac arrest 0 1 2 3 4 5 Seizures 0 1 2 3 4 5 Minor head injuries 0 1 2 3 4 5 Animal bites 0 1 2 3 4 5 Ingestions and poisonings 0 1 2 3 4 5 Overdose of sedative, hypnotics, opiates 0 1 2 3 4 5 Snake bites 0 1 2 3 4 5 Minor burns 0 1 2 3 4 5 Shock 0 1 2 3 4 5 Open wounds 0 1 2 3 4 5 Respiratory Croup 0 1 2 3 4 5 Influenza 0 1 2 3 4 5 Tracheobronchitis 0 1 2 3 4 5 Bronchitis 0 1 2 3 4 5 COPD (chronic obstructive pulmonary disease) 0 1 2 3 4 5 Asthma 0 1 2 3 4 5 URI (upper respiratory infection) 0 1 2 3 4 5 Obstructive Sleep Apnea 0 1 2 3 4 5 Pneumonia: Viral 0 1 2 3 4 5 Bacterial 0 1 2 3 4 5 Sinusitis: Bacterial 0 1 2 3 4 5 Nonbacterial 0 1 2 3 4 5 Cardiovascular System Congestive heart failure 0 1 2 3 4 5 Chronic obstructive pulmonary disease 0 1 2 3 4 5 Stasis ulcer of lower extremities 0 1 2 3 4 5 Angina 0 1 2 3 4 5 Pericarditis 0 1 2 3 4 5 Coronary artery disease 0 1 2 3 4 5 Functional murmurs 0 1 2 3 4 5 Congenital heart disease 0 1 2 3 4 5 Hypertension 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 2 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) OB/GYN Candida vaginitis 0 1 2 3 4 5 Dysmenorrhea 0 1 2 3 4 5 Abnormal pap smear findings 0 1 2 3 4 5 Pap smears 0 1 2 3 4 5 Trichomonal vaginitis 0 1 2 3 4 5 Atrophic vaginitis 0 1 2 3 4 5 Fibrocystic breast disease 0 1 2 3 4 5 Menopause 0 1 2 3 4 5 Intrapartum medications 0 1 2 3 4 5 Bartholin's cyst/abscess 0 1 2 3 4 5 Preparation for childbirth 0 1 2 3 4 5 Pregnancy - diagnosis and referral 0 1 2 3 4 5 Pain relief in active phase of labor 0 1 2 3 4 5 Medications in the third stage 0 1 2 3 4 5 Dysfunctional uterine bleeding 0 1 2 3 4 5 Medications in the postpartum phase 0 1 2 3 4 5 Rh blood factor 0 1 2 3 4 5 Mastitis 0 1 2 3 4 5 Birth control methods 0 1 2 3 4 5 Prenatal care 0 1 2 3 4 5 Fetal well-being 0 1 2 3 4 5 Nausea and vomiting with pregnancy 0 1 2 3 4 5 GI System Constipation 0 1 2 3 4 5 Diarrhea (simple) 0 1 2 3 4 5 Acute gastroenteritis 0 1 2 3 4 5 Cholecystitis 0 1 2 3 4 5 Pyloric stenosis 0 1 2 3 4 5 Colic 0 1 2 3 4 5 Appendicitis 0 1 2 3 4 5 Skin Warts 0 1 2 3 4 5 Basal cell carcinoma 0 1 2 3 4 5 Scabies 0 1 2 3 4 5 Impetigo 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 3 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Skin - cont. Diaper dermatitis 0 1 2 3 4 5 Acne 0 1 2 3 4 5 Folliculitis 0 1 2 3 4 5 Furuncles 0 1 2 3 4 5 Carbuncles 0 1 2 3 4 5 Herpes simplex 0 1 2 3 4 5 Herpes zoster 0 1 2 3 4 5 Malignant melanoma 0 1 2 3 4 5 Pityriasis Rosea 0 1 2 3 4 5 Contact dermatitis 0 1 2 3 4 5 Tinea corporis 0 1 2 3 4 5 Tinea pedis 0 1 2 3 4 5 Ears, Nose and Throat Epistaxis 0 1 2 3 4 5 Otitis externa 0 1 2 3 4 5 Serous otitis media 0 1 2 3 4 5 Acute purulent otitis media 0 1 2 3 4 5 Allergic rhinitis 0 1 2 3 4 5 Pharyngitis 0 1 2 3 4 5 Oral candidiasis 0 1 2 3 4 5 Eye Conjunctivitis 0 1 2 3 4 5 Strabismus 0 1 2 3 4 5 Chalazion 0 1 2 3 4 5 Stye 0 1 2 3 4 5 Musculoskeletal Osteoporosis 0 1 2 3 4 5 Osteomyelitis 0 1 2 3 4 5 Rheumatoid arthritis 0 1 2 3 4 5 Juvenile diabetes 0 1 2 3 4 5 Gout 0 1 2 3 4 5 Minor sprains and strains 0 1 2 3 4 5 Osteoarthritis 0 1 2 3 4 5 Carpal tunnel syndrome 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 4 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Musculoskeletal - cont. Scoliosis 0 1 2 3 4 5 Tendonitis 0 1 2 3 4 5 Bursitis 0 1 2 3 4 5 Muscular dystrophy 0 1 2 3 4 5 Parasitic Infections Pinworms 0 1 2 3 4 5 Ascariasis 0 1 2 3 4 5 Pediculosis 0 1 2 3 4 5 Genitourinary System Syphilis 0 1 2 3 4 5 Chlamydia 0 1 2 3 4 5 Herpes 0 1 2 3 4 5 Cystitis 0 1 2 3 4 5 Pyelonephritis 0 1 2 3 4 5 Urinary tract infection 0 1 2 3 4 5 Benign prostatic hypertrophy 0 1 2 3 4 5 Vulvovaginitis 0 1 2 3 4 5 Hypospadias 0 1 2 3 4 5 Hydrocele 0 1 2 3 4 5 Gonococcal infections 0 1 2 3 4 5 Prostatitis 0 1 2 3 4 5 Nervous System Vasovagal syncope 0 1 2 3 4 5 Migraine headaches 0 1 2 3 4 5 Multiple sclerosis 0 1 2 3 4 5 Headaches 0 1 2 3 4 5 Head injury 0 1 2 3 4 5 Tension 0 1 2 3 4 5 Anxiety 0 1 2 3 4 5 Parkinson s 0 1 2 3 4 5 Alzheimer's 0 1 2 3 4 5 Bell s Palsy 0 1 2 3 4 5 TIA (transient ischemic attacks) 0 1 2 3 4 5 Trigeminal neuralgia 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 5 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Endocrine Type I diabetes mellitus 0 1 2 3 4 5 Type II diabetes mellitus 0 1 2 3 4 5 Graves disease 0 1 2 3 4 5 Addison's disease 0 1 2 3 4 5 Juvenile diabetes 0 1 2 3 4 5 Hypoglycemia 0 1 2 3 4 5 Hypothyroidism 0 1 2 3 4 5 Hematological Folic acid deficiency anemia 0 1 2 3 4 5 Aplastic anemia 0 1 2 3 4 5 Iron deficiency 0 1 2 3 4 5 Sickle cell anemia 0 1 2 3 4 5 Pernicious anemia 0 1 2 3 4 5 Psychosocial Depression 0 1 2 3 4 5 Suicide 0 1 2 3 4 5 Obesity 0 1 2 3 4 5 Grief 0 1 2 3 4 5 Anxiety 0 1 2 3 4 5 Anorexia 0 1 2 3 4 5 Bulimia 0 1 2 3 4 5 Collaboration Family, support system, community resources 0 1 2 3 4 5 Consulting with Physicians 0 1 2 3 4 5 Consulting with Pharmacists 0 1 2 3 4 5 Consulting with Speech Therapist 0 1 2 3 4 5 Consulting with Dietician and Diet Aide 0 1 2 3 4 5 Consulting with Occupational Therapist 0 1 2 3 4 5 Referral to Pastoral Services 0 1 2 3 4 5 Drug Therapy Prescription 0 1 2 3 4 5 Over the counter (OTC) 0 1 2 3 4 5 Herbal drugs 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 6 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Drug Therapy - cont. Knowledge of pharmacology 0 1 2 3 4 5 Knowledge of pharmacokinetics 0 1 2 3 4 5 Knowledge of drug interactions 0 1 2 3 4 5 Knowledge of side effects 0 1 2 3 4 5 Knowledge of potential adverse reactions: Allergic reactions 0 1 2 3 4 5 Anaphylaxis reaction 0 1 2 3 4 5 TPN/Lipid Management 0 1 2 3 4 5 Management/Titration of IV Therapies 0 1 2 3 4 5 IV/PO Antibiotic Therapy and understanding of cultures 0 1 2 3 4 5 Dispensing Medication Monitoring drug therapy 0 1 2 3 4 5 Management of controlled substances 0 1 2 3 4 5 Injections 0 1 2 3 4 5 Non-Pharmacologic Interventions Medical nutrition therapy 0 1 2 3 4 5 Exercise 0 1 2 3 4 5 Cessation of substance abuse (alcohol, tobacco) 0 1 2 3 4 5 Mental health issues (stress management, depression) 0 1 2 3 4 5 Obesity management 0 1 2 3 4 5 Tube Feeding Management 0 1 2 3 4 5 Miscellaneous Public health and health promotion 0 1 2 3 4 5 Research 0 1 2 3 4 5 Quality assurance 0 1 2 3 4 5 Leadership and teaching skills 0 1 2 3 4 5 Legal and ethical issues 0 1 2 3 4 5 Confidentiality 0 1 2 3 4 5 Cultural awareness 0 1 2 3 4 5 Self evaluation to improve patient care 0 1 2 3 4 5 Continuing education 0 1 2 3 4 5 Working within scope of practice 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 7 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Miscellaneous - cont. Discharge planning / collaboration 0 1 2 3 4 5 Suturing 0 1 2 3 4 5 Cell biopsy 0 1 2 3 4 5 Starting IV 0 1 2 3 4 5 Casting and splinting 0 1 2 3 4 5 Radiographic interpretation (initial) 0 1 2 3 4 5 Informed consent 0 1 2 3 4 5 Explanation to patient/family 0 1 2 3 4 5 Documentation 0 1 2 3 4 5 Venipuncture 0 1 2 3 4 5 Ultrasounds 0 1 2 3 4 5 Programs OSHA (Occupational Safety and Health Administration) 0 1 2 3 4 5 Medicare and Medicaid 0 1 2 3 4 5 CLIA waiver (Clinical Laboratory Improvement Amendments) 0 1 2 3 4 5 TJC (The Joint Commission) 0 1 2 3 4 5 HEDIS (Health Plan Employer Data and Information Set) 0 1 2 3 4 5 DQIP (Diabetes Quality Improvement Program) 0 1 2 3 4 5 HIPAA (Health Insurance Portability & Accountability Act) 0 1 2 3 4 5 HCAHPS 0 1 2 3 4 5 Age Specific Competencies Newborn/neonate (birth-30 days) 0 1 2 3 4 5 Infant (31 days-1 year) 0 1 2 3 4 5 Toddler (ages 2-3 years) 0 1 2 3 4 5 Preschool (ages 4-5 years) 0 1 2 3 4 5 School age (ages 6-12 years) 0 1 2 3 4 5 Adolescents (ages 13-21 years) 0 1 2 3 4 5 Young adult (ages 22-39 years) 0 1 2 3 4 5 Adults (ages 40-64 years) 0 1 2 3 4 5 Older adult (ages 65-79 years) 0 1 2 3 4 5 Elderly (ages 80+ years) 0 1 2 3 4 5 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 8 of 9

1 No 2 Some (Require Assistance) 3 Intermittent (May Require Assistance) 4 d (Performs without Assistance) 5 Very d (Able to Teach/Supervise) Please list any Additional Skills: 1. 2. 3. 4. Additional training: 1. 2. 3. 4. Additional equipment: 1. 2. 3. 4. Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct. Signature Date 2014 Cross Country Healthcare, Inc. Rev. 04/14 F0839 Physician Assistant 9 of 9