_ XXX-XX- Print Name Last 4 of SS # Date Completed 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 (has never done or observed) 2 - Requires Training (In-Service) - not performed within last 36 months 3 - Limited (requires assistance or training) - performed within the last 24 months 4 - d (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 months EQUIPMENT: NITROGEN TANK 1 2 3 4 5 CUSA 1 2 3 4 5 LASER EQUIPMENT 1 2 3 4 5 CELL SAVER 1 2 3 4 5 AUTOTRANSFUSION DRAINING 1 2 3 4 5 AUTOCLAVE 1 2 3 4 5 CRYO-OPTHALMIC UNIT 1 2 3 4 5 STERIS UNIT 1 2 3 4 5 VIDEO SYSTEMS/CAMERA 1 2 3 4 5 PNEUMATIC TOURNIQUET 1 2 3 4 5 ELECTROSURGICAL UNIT 1 2 3 4 5 VENODYNE 1 2 3 4 5 DERMATONE/MESH GRAFT 1 2 3 4 5 FIBEROPTIC EQUIPMENT 1 2 3 4 5 CIDEX SOAK 1 2 3 4 5 PULSEVAC IRRIGATION 1 2 3 4 5 MICROSCOPES 1 2 3 4 5 Version: 07/03/2012 Page 1 out of 8
EQUIPMENT: SAW / DRILLS 1 2 3 4 5 FRACTURE TABLES 1 2 3 4 5 FIBER OPTIC LAMINATOR 1 2 3 4 5 STAPLING DEVICES 1 2 3 4 5 CAVITRON 1 2 3 4 5 CARDIOVASCULAR RIB RESECTION 1 2 3 4 5 INTRA-AORTIC BALLOON PUMP 1 2 3 4 5 AORTIC ANEURYSM 1 2 3 4 5 AORTIC FEMORAL BYPASS GRAFT 1 2 3 4 5 LOBECTOMY 1 2 3 4 5 PACEMAKERS 1 2 3 4 5 THORACOTOMY 1 2 3 4 5 FEMORAL/POPLITEAL BYPASS 1 2 3 4 5 ENDOSCOPIC VEIN HARVESTING 1 2 3 4 5 ASV/VSD/SEPTAL DEFECTS 1 2 3 4 5 OFF PUMP BYPASS 1 2 3 4 5 CARDIAC CATH LAB 1 2 3 4 5 VALVE REPLACEMENT 1 2 3 4 5 CORONARY ARTERY BYPASS 1 2 3 4 5 GENERAL SURGERY SPLENECTOMY 1 2 3 4 5 BOWEL RESECTION 1 2 3 4 5 VAGOTOMY 1 2 3 4 5 ILEOSTOMY 1 2 3 4 5 ORGAN PROCUREMENT 1 2 3 4 5 TRACHEOTOMY 1 2 3 4 5 ABDOMINAL PERINEAL RESECT. 1 2 3 4 5 HERNIORRHAPHY 1 2 3 4 5 THYROIDECTOMY 1 2 3 4 5 Version: 07/03/2012 Page 2 out of 8
GENERAL SURGERY COLOSTOMY 1 2 3 4 5 SAPHENOUS VEIN LIGATION 1 2 3 4 5 ADRENALECTOMY 1 2 3 4 5 MASTECTOMY 1 2 3 4 5 CHOLANGIOGRAM 1 2 3 4 5 PANCREATECTOMY 1 2 3 4 5 HIATAL HERNIORRHAPHY 1 2 3 4 5 GASTRECTOMY 1 2 3 4 5 NEUROLOGY SHUNT PROCEDURES VP/VA/LP 1 2 3 4 5 BURR HOLES 1 2 3 4 5 MYLELOMENINGOCELE REPAIR 1 2 3 4 5 CAROTID LIGATION 1 2 3 4 5 SPINAL FUSIONS 1 2 3 4 5 CERVICAL SYMPHATHECTOMY 1 2 3 4 5 VENTRICULOSTOMY 1 2 3 4 5 INSERTION OF NERVE STIMULUS 1 2 3 4 5 LAPAROSCOPIC PROCEDURES 1 2 3 4 5 HALO TRACTION 1 2 3 4 5 SUBDURAL HEMATOMA 1 2 3 4 5 LAMINECTOMY 1 2 3 4 5 CRANIOPLASTY 1 2 3 4 5 DISECTOMY 1 2 3 4 5 CRANIOTOMY 1 2 3 4 5 ENDOSCOPY LARYNGOSCOPY 1 2 3 4 5 CULDOSCOPY 1 2 3 4 5 TUBAL LIGATION 1 2 3 4 5 APPENDECTOMY 1 2 3 4 5 THORACOSCOPY 1 2 3 4 5 Version: 07/03/2012 Page 3 out of 8
ENDOSCOPY HYSTEROSCOPY 1 2 3 4 5 PELVISCOPY 1 2 3 4 5 COLONOSCOPY 1 2 3 4 5 VAGINAL HYSTERECTOMY 1 2 3 4 5 GASTROSCOPY 1 2 3 4 5 MEDIASTINOSCOPY 1 2 3 4 5 BRONCHOSCOPY 1 2 3 4 5 SALPINGO-OOPHORECTOMY 1 2 3 4 5 CYCTOSCOPY 1 2 3 4 5 SIGMOIDOSCOPY 1 2 3 4 5 ESOPHAGOSCOPY 1 2 3 4 5 HERNIA REPAIR 1 2 3 4 5 CHOLECYSTECTOMY 1 2 3 4 5 COLON RESECTION 1 2 3 4 5 EAR, NOSE & THROAT SEPTOPLASTY 1 2 3 4 5 ADENOIDECTOMY 1 2 3 4 5 THRACHEOSTOMY 1 2 3 4 5 RADICAL NECK 1 2 3 4 5 MASTOIDECTOMY 1 2 3 4 5 CALDWELL-LUC 1 2 3 4 5 SINUSOTOMY 1 2 3 4 5 TONSILLECTOMY 1 2 3 4 5 CLEFT LIP 1 2 3 4 5 MANDIBULECTOMY 1 2 3 4 5 LARYNEGECTOMY 1 2 3 4 5 GYNECOLOGY TUBAL LIGATION 1 2 3 4 5 ABDOMINAL HYSTERECTOMY 1 2 3 4 5 RADIUM INSERTION 1 2 3 4 5 Version: 07/03/2012 Page 4 out of 8
GYNECOLOGY DILATION/CURETTAGE 1 2 3 4 5 VAGINECTOMY 1 2 3 4 5 SHIRODKAR PROCEDURE 1 2 3 4 5 C-SECTION 1 2 3 4 5 LASER SURGERY 1 2 3 4 5 TOP 1 2 3 4 5 VAGINAL HYSTERECTOMY 1 2 3 4 5 HYSTERECTOMY - ABDOMINAL 1 2 3 4 5 HYSTERECTOMY - VAGINAL 1 2 3 4 5 OPTHAMOLOGY RETINAL DETACHMENT 1 2 3 4 5 CORNEAL TRANSPLANT 1 2 3 4 5 CATARACT EXTRACTION 1 2 3 4 5 ENUCLEATION 1 2 3 4 5 SCLERAL BUCKLE 1 2 3 4 5 IOL IMPLANTS 1 2 3 4 5 ORBITAL IMPLANTS 1 2 3 4 5 ORBITAL FRACTURES 1 2 3 4 5 ORTHOPEDIC DISLOCATION REPAIRS 1 2 3 4 5 ARTHOTOMY 1 2 3 4 5 TOTAL JOINT REPLACEMENTS 1 2 3 4 5 ACHILLES TENDON REPAIR 1 2 3 4 5 PATELLECTOMY 1 2 3 4 5 EXTERNAL COMPRESSIONS 1 2 3 4 5 ORIF 1 2 3 4 5 AMPUTATION 1 2 3 4 5 SPICA CAST 1 2 3 4 5 REDUCTION OF EXTREMITIES 1 2 3 4 5 TENDON IMPLANTS 1 2 3 4 5 Version: 07/03/2012 Page 5 out of 8
ORTHOPEDIC ARTHROSCOPY 1 2 3 4 5 HIP COMPRESSION NAILS 1 2 3 4 5 TRANSPLANTS MULTI ORGANS 1 2 3 4 5 BONE MARROW 1 2 3 4 5 HEART/LUNG 1 2 3 4 5 SKIN 1 2 3 4 5 CORNEAL 1 2 3 4 5 LIVER 1 2 3 4 5 PANCREAS 1 2 3 4 5 KIDNEY 1 2 3 4 5 BONE 1 2 3 4 5 HARVESTING 1 2 3 4 5 UROLOGY HYPOSPADIUS REPAIR 1 2 3 4 5 LITHOTRIPSY 1 2 3 4 5 PROSTATACTOMY 1 2 3 4 5 URETEROSCOPY 1 2 3 4 5 URETEROLITHOMY 1 2 3 4 5 CIRCUMCISION 1 2 3 4 5 ORCHIECTOMY 1 2 3 4 5 VASECTOMY 1 2 3 4 5 CYSTOSCOPY 1 2 3 4 5 NEPHRECTOMY 1 2 3 4 5 IMPLANTS 1 2 3 4 5 CYSTECTOMY 1 2 3 4 5 VASCULAR EMBOLECTOMY 1 2 3 4 5 AORTIC ANEURYSM 1 2 3 4 5 THROMBECTOMY 1 2 3 4 5 Version: 07/03/2012 Page 6 out of 8
VASCULAR ANGIOGRAPHY 1 2 3 4 5 AORTIC ENDARTERECTOMY 1 2 3 4 5 PERIPHERAL VASCULAR BYPASS 1 2 3 4 5 VENA CAVA LIGATION 1 2 3 4 5 CAROTID ANEURYSM/GRAFT 1 2 3 4 5 PLASTICS OTOPLASTY 1 2 3 4 5 FACE LIFT 1 2 3 4 5 REDUCTION 1 2 3 4 5 ADBOMINAL LIPECTOMY 1 2 3 4 5 SKIN GRAFTING 1 2 3 4 5 BREAST AUGMENTATION 1 2 3 4 5 SCAR REVISIONS 1 2 3 4 5 BLEPHAROPLASTY 1 2 3 4 5 LIPOSUCTION 1 2 3 4 5 MAMMOPLASTY 1 2 3 4 5 RECONSTRUCTION 1 2 3 4 5 TRAUMA MVA'S 1 2 3 4 5 BURNS 1 2 3 4 5 STAB WOUNDS 1 2 3 4 5 TRAUMATIC AMPUTATIONS 1 2 3 4 5 GUNSHOT WOUNDS 1 2 3 4 5 JUMPERS 1 2 3 4 5 DRUG OVERDOSE 1 2 3 4 5 LEVEL 1 TRAUMA 1 2 3 4 5 IN PATIENT HOSPITAL 1 2 3 4 5 OUT PATIENT SETTING 1 2 3 4 5 AGE APPROPRIATE CARE NEWBORN (BIRTH-30 DAYS) 1 2 3 4 5 Version: 07/03/2012 Page 7 out of 8
AGE APPROPRIATE CARE INFANT (30 DAYS - 1 YEAR) 1 2 3 4 5 TODDLER (1-3 YEARS) 1 2 3 4 5 PRESCHOOLER (3-5 YEARS) 1 2 3 4 5 SCHOOL AGE (5-12 YEARS) 1 2 3 4 5 ADOLESCENTS (12-18 YEARS) 1 2 3 4 5 YOUNG ADULTS (18-39 YEARS) 1 2 3 4 5 MIDDLE ADULTS (39-64 YEARS) 1 2 3 4 5 OLDER ADULTS (64+ YEARS) 1 2 3 4 5 The information represented above is true and correct to the best of my knowledge. I also authorize Specialty Professional Services, Corp to share the above skills checklist with its facility clients. Signature Date Completed Fax: 718-225-9421 Version: 07/03/2012 Page 8 out of 8