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REGISTERED NURSE
INFECTION CONTROL CHECKLIST
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NAME
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LAST 4 OF SSN
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DATE
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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.
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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.
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Proficiency Scale:
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1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
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Rating Stars (Click)
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Surveillance
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1
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2
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3
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4
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Performs targeted surveillance
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Outbreak investigations
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Collaboration with Infection Control Committee
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Collaboration with Hospital
Epidemiologist
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Performance improvement
projects related in communicable diseases
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Collects, monitors, and
maintains data using facility HER
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Utilize Center for Disease
Control (CDC)
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Infection criteria
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TB, AIDS
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Documentation and
investigation techniques
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Rounds of hospital units
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Case definition, and other
related patient care issues
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Monitor infection control practices
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Nosocomial infections or AHIs, MRSAs
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Health care workers
exposures
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Tracing the possible
sources of infection or transmission of microorganisms
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Rating Stars
(Click)
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Identification of Problems
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1
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2
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3
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4
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Regularly meet with the
hospital Epidemiologist
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Risk reduction among patients, facility staff,
volunteers, students, and visitors
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Understand the transmission
and break of infections
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Identification of
epidemiologically important issues for Infection Control Committee
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Rating Stars
(Click)
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Hospital
Epidemiologist, and Administration
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1
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2
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3
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4
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Design COA including Surveillance, Outbreak
Investigations, and Performance Improvement Projects
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Communicable diseases
reporting as required by the state and the local health authority
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Compliance with federal and
state laws regarding medical wastes,
chemicals in the workplace, infectious disease exposures
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OSHA NIOSH standards
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Blood borne pathogens and
respiratory pathogens
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Chart review
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Rating Stars
(Click)
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Policies and Procedures
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1
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2
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3
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4
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Infection Control policies
associated with infection
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Staff practices associated
with infection contol
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Professional guidelines
(CDC, APIC, etc.)
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The Joint Commission
guidelines on infection Control
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Infection Control Plan to
reflect and meet any required changes
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Rating Stars
(Click)
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Coordination
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1
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2
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3
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4
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Acts as department liaison
for Infection Control Department
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Act as consultant for the
facility Infection Control activities
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Interdepartment and
personnel coordination on risk
reduction, transmission and improved infection control practices
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Provide coordinated
services to patients for the improvement of overall
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Patient care
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Rating Stars
(Click)
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Education
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1
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2
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3
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4
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In-services of all and
current employees on Infection Control
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Orientation programs of new
employees on Infection Control
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Infection Control
techniques and Policies and Procedures
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Rating Stars
(Click)
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EMR
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1
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2
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3
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4
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Epic
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Cerner
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Eclipsys
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McKesson
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Meditech
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Other Computerized System
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Computerized Physician
Order Entry
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Bar Coding for Medication
Administration
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MY EXPERIENCE IS
PRIMARILY IN:
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Unit
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No. of Years
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Unit
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No. of Years
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BURN
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POST PARTUM
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CRITICAL UNIT
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LABOR & DELIVERY
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PACU
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NEWBORN NURSERY
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NEUROLOGY
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LEVEL II NICU
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TELEMETRY
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LEVEL III NICU
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MEDICAL
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PICU
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SURGICAL
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PEDIATRICS
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ONCOLOGY
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OB/GYN
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ORTHOPEDICS
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PSYCHIATRY
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OPERATING ROOM
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RRT
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EMERGENCY ROOM
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CRT
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TRAUMA CENTER
LEVEL 1
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COMMUNITY ER
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RURAL ER
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Rating Stars
(Click)
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AGE APPROPRIATE CARE
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1
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2
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3
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4
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Newborn/Neonatal (birth –
30 days)
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Infant (30 days-1 year)
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Toddler (1-3 years)
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Preschool (3-5 years)
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School Age Children (5-12
years)
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Adolescent (12-17 years)
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Young Adults (18-44 years)
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Middle Adults (45-64 years)
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Older Adults (>65 years)
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