CYNET_SYSTEMS_MAIN_LOGO.gif   EEG Technologist 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) PERFORM THE FOLLOWING: 1 2 3 4  
10-20 Electrode Placement  
Portable Recording in Adult ICU  
Portable Recording in Pediatric ICU  
Portable Recording in NICU  
ECI-Brain Death Recording  
Ambulatory EEG  
Sleep Deprived EEG  
Sleep EEG  
EMG  
Rating Stars (Click) EVOKED POTENTIALS 1 2 3 4  
Somatosensory Evoked Potentials (SSEP)  
Motor Evoked Potential (OR)  
Visual Evoked Potential  
Auditory Evoked Potential  
Assist with Nerve Conduction Studies/Electromyography  
Rating Stars (Click) EQUIPMENT 1 2 3 4  
Xltek  
Nihon Koden  
Biologic  
Grass  
Specify:  
Rating Stars (Click) DOCUMENTATION 1 2 3 4  
Obtain Patient History  
Changes in Patient Status  
Stimulation  
Hyperventilation  
Post Hyperventilation  
Interpreting EEG Patterns  
Rating Stars (Click) MISCELLANEOUS 1 2 3 4  
National Patient Safety Goals  
Computerized Charting  
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  
Rating Stars (Click) MY EXPERIENCE IS IN THE FOLLOWING SETTINGS: 1 2 3 4  
Adult Inpatient  
Adult Outpatient  
Pediatric Inpatient  
Pediatric Outpatient  
Neonatal  
Management  
Rehabilitation  
Intraoperative Monitoring Experience  
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      
CERTIFICATIONS   Expiry Date :   
  BLS
   
  EEG Credential (ABRET)
   
  CNIM
   
  EP
   
  Registered EEG Tech
   
  Specify:  
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)