CYNET_SYSTEMS_MAIN_LOGO.gif   ANESTHESIA TECH COMPETENCY SKILLS CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group 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) Experience 1 2 3 4  
HOSPITAL / OFFICE  
MDA / SUPERVISED  
SOLO  
TEACHING  
INHALATION AGENT  
INTRAVENOUS AGENT  
PRE-PERI-POST PREP & MEDICATION  
AUTO-TRANSFUSION TECHNIQUES  
CARDIOPULMONARY BYPASS TECH  
HYPO/HYPERTENSIVE TECHNIQUES  
HYPOTHERMIA  
INTRAVENOUS ADMINISTRATION OF BLOOD  
INTRAVENOUS ADMINISTRATION OF FLUID  
INTRAVENOUS ADMINISTRATION OF MUSCLE RELAXANTS  
INTRAVENOUS ADMINISTRATION OF PLASMA  
INTRAVENOUS ADMINISTRATION OF PLASMA EXPANDERS  
INTRAVENOUS ADMINISTRATION OF VASOACTIVE DRUGS  
INTRAVENOUS CATHETER PLACEMENT  
MECHANICAL VENTILLATION  
PLACEMENT OF ARTERIAL LINES  
PLACEMENT OF CENTRAL VENOUS LINES  
PLACEMENT OF SWAN-GANZ  
RESUSCITATION TECHS AND THERAPY  
EPIDURAL AND CAUDAL  
FIELD BLOCKS  
INFILTRATION  
INTRAVENOUS  
LOWER EXTREMITY  
SPINAL  
TOPICAL  
UPPER EXTREMITY  
Rating Stars (Click) UPPER EXTREMITY 1 2 3 4  
GENERAL SURGERY  
NEUROLOGICAL  
OPEN HEART  
OB/GYN  
ORTHOPEDIC  
PEDIATRICS  
PAIN MANAGEMENT  
THORACIC  
TRAUMA / BURNS  
VASCULAR  
Rating Stars (Click) BLOCKS 1 2 3 4  
EPIDURAL  
FIELD BLOCK  
SPINAL-DIFFERENTIA  
STEROID, ALCOHOL AND DRUB PHENOL BLO  
SYMPATHETIC BLOCK  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1      
COMMUNITY ER      
RURAL ER      
Rating Stars (Click) AGE APPROPRIATE CARE 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)