* = Required Information

First Name * Last Name *
Social Security Number * Date *
Email *
Please indicate your level of experience (0, 1, 2, or 3)
0 = Theory, no practice  1 = Limited  2 = Confident  3 = Very Confident
Provide AM care 0123
Provide PM care 0123
Assist patient with ambulation 0123
Provide back and skin care 0123
Give a bed bath 0123
Care for bedsores 0123
Care for Foley catheter 0123
Provide colostomy care 0123
Apply cold compresses 0123
Change non-sterile dressings 0123
Administer enema 0123
Assist with exercise/ROM 0123
Provide hair care 0123
Use correct hand washing technique 0123
Calculate and record intake and output 0123
Use correct isolation technique 0123
Complete menu with patient 0123
Provide oral hygiene 0123
Provide perineal care 0123
Provide post-mortem care 0123
Shave patient 0123
Transfer/transport patient 0123
Take vital signs: TPR & BP 0123
Apply restraints 0123
Universal precautions 0123
Feed patient 0123
Dispose of sharps 0123
Use of correct side rail position 0123
Specimen collection (urine, stool, sputum) 0123
Follow fluid restrictions 0123
Use of special mattresses 0123
Provide ostomy care 0123
Administer sitz bath 0123
Weigh patient/use of scale 0123
Apply TED hose 0123
Use of aqua-K pads 0123
Complete admission paper work 0123
Discharge a patient 0123
Stock supplies 0123
Clean equipment 0123
Answer phone 0123
Assist with care of the patient with alcoholism 0123
Assist with care of the patient with amputation 0123
Assist with care of the patient with arthritis 0123
Assist with care of the blind patient 0123
Assist with care of the patient with cancer 0123
Assist with care of the patient with cataracts 0123
Assist with care of the comatose patient 0123
Assist with care of the confused/disoriented patient 0123
Assist with care of the patient with convulsions 0123
Assist with care of the deaf patient 0123
Assist with care of the drug abuse patient 0123
Assist with care of the patient with diabetes 0123
Assist with care of the patient with fractures 0123
Assist with care of the patient with a gastrotomy 0123
Assist with care of the geriatric patient 0123
Assist with care of the patient with dementia 0123
Assist with care of the patient with heart condition 0123
Assist with care of the incontinent patient 0123
Assist with care of the infant 0123
Assist with care of the child 0123
Assist with care of the patient with multiple sclerosis 0123
Assist with care of the patient with a pacemaker 0123
Assist with care of the paraplegic patient 0123
Assist with care of the quadriplegic patient 0123
Assist with care of the patient with Parkinson's disease 0123
Assist with care of the retarded patient 0123
Assist with care of the senile patient 0123
Assist with care of the patient in shock 0123
Assist with care of the patient with stroke 0123
Assist with care of the terminally ill patient 0123