CYNET_SYSTEMS_MAIN_LOGO.gif   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 LEVEL 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)