CYNET_SYSTEMS_MAIN_LOGO.gif   STERILE PROCESSING 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) Processing 1 2 3 4  
Single instruments   
Endoscopes   
Repair   
Sets/ Trays   
Care of instruments   
Other (list):   
Rating Stars (Click) Decontamination 1 2 3 4  
Manual cleaning  
Washer sterilizer  
Soiled linen  
Disinfectants   
Sharps  
Disposable items  
Cleaning equipment   
Detergents   
Dress code   
Other (list):   
Rating Stars (Click) Steam Sterilization 1 2 3 4  
Chart recording  
Biological monitoring  
Time   
Testing/ Monitoring  
Other (list):  
Rating Stars (Click) Tests 1 2 3 4  
Test control   
Recording  
Other (list):   
Rating Stars (Click) Assembly andPreparation 1 2 3 4  
Wrapping materials  
Autoclave tape  
Dust covers   
Proper towel/ linen folding  
Proper labeling  
Expiration dates  
Packing for steam  
Heat sealing  
Instrument count sheets  
Placing instruments on trays  
Other (list):   
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)