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REGISTERED NURSE OCCUPATIONAL AND EMPLOYEE HEALTH 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)
TRAUMA
1
2
3
4
Care of Patient with:
Minor Trauma
Major Trauma
MAST Suit
Rating Stars (Click)
BURNS
1
2
3
4
Care of Patient with:
First Degree
Second Degree
Third Degree
Electrocution
Hazardous Materials Exposure
Rating Stars (Click)
LACERATIONS
1
2
3
4
Care of Patient with:
Assessment
Cleansing
Steri-Strips
Dressing
Rating Stars (Click)
SPRAIN/STRAIN
1
2
3
4
Assessment
Carpal Tunnel
Tendonitis
Epicondylitis
Rating Stars (Click)
PHYSICALS
1
2
3
4
Safety
Return to Work
Respirator
Vital Signs
Height/Weight
Blood Draw
Medical Referral Form
Medical Certification Form
Medical History Questionnaire
Potassium Iodine Assessment
Rating Stars (Click)
RESTRICTIONS
1
2
3
4
Temporary Restrictions
Permanent Restrictions
Pulmonary Function
Audiometry
Vision Testing
X-ray
Urine Testing
Drug Testing
Breathalyzer
Rating Stars (Click)
IMMUNIZATIONS
1
2
3
4
Havrix (Hepatitis A)
Influenza Vaccine
Meningitis Vaccine
Tetanus & Diphtheria
Oral Typhoid Vaccine
Polio Vaccine
Hepatitis B Vaccine
Japanese Encephalitis B
Rabies Vaccine
Typhim (Injectable Type)
Yellow Fever Vaccine
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 LEV
EL 1
COMMUNITY ER
RURAL ER
Rating Stars (Click)
Age Specific Competencies
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)
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