* = Required Information

Name * 
            (Last,Middle,First)

The following checklist is used to assess your experience and skills and help your Nurse Advisor place you in the proper assignment. Please provide a self-assessment of your skills using the following guidelines:

  • 1 - No experience
  • 2 - Require training
  • 3 - Have performed this task and able to perform without supervision
  • 4 - Most experienced and able to perform independently
  • 5 - Able to teach and supervise

* I understand that the information provided in this application is true to the best of my knowledge. I authorize the release of the information in this document to LJD Healthcare Staffing and facilities where I may be employed.

Cardiac 1 2 3 4 5
A - Line (Transducer setup D/C)
Assisting with Insertion of Central Lines
Automatic Internal Cardioverter Defib
Balloon Pump (IABP) Setup
Assisting with Balloon Pump Insertion
Assisting with EPS / Ablation Therapy
Assisting with Cardiac Catheterization
Cardiac Arrest / CPR
Defibrillation / Cardioversion
Interpretation of 12 Lead EKG
Interpretation of Arrhythmias
Interpretation of Hemodynamic Monitoring
Pacemakers - External
Pacemakers - Permanent
Pacemakers - Temporary
Sheath Removal - Femoral
SVO2 Monitoring
Swan Ganz (Transducer setup D/C)
Care of Patient With 1 2 3 4 5
Acute MI / Unstable Angina
Aneurysm
Cardiogenic / Hypovolemic Shock
CHF
Pre/Post Cardiac Surgery
Pre/Post Caridaac Cath
Use and Administration of the Following 1 2 3 4 5
Atropine
Digoxin
Dobutrex
Dopamine
Inderal
Inocor
Insulin Drip
Nipride
Isuprel
Lidocaine
Neosynephrine
NTG
Prep./Titration of Emergency Drugs
Pronestyl
Thrombolytic
Titrate Morphine
Verapamil
Gastrointestinal 1 2 3 4 5
Enterostomal Care
Gastrostomy Tube
Jejunostomy Tube
BG Tube Insertion
Care of Patient With 1 2 3 4 5
Bowel Obstruction
ERCP
Esophageal Bleeding
G.I. Bleed
Liver Transplant
Pancreatitis
Paralitic IIeus
Whipple Procedure
Genitourinary / Renal 1 2 3 4 5
Electrolyte Imbalance / Replacement
Foley Catheter Insertion
GU Irrigations
Nephrostomy Tube
Suprapubic Tube
Peritoneal Dialysis
HemoDialysis
Care of Patient With 1 2 3 4 5
Nephrectomy
Renal Failure
Renal Transplant
Renal Trauma
Shunts and Fistulas
T.U.R.P.
Neurology 1 2 3 4 5
Assessment of Neuro Signs
Assist with Lumbar Puncture
Crutchfield Tongs
Glascow Coma Scale
Halo Traction
ICP Monitoring
Seizure Precautions
Stryker frame
Care of Patient With 1 2 3 4 5
Cranial Hemorrhage
CVA
Neuro Injury / Trauma
Overdose
Pre/Post Neuro Surgery
Seizure Activity
Use and Administration of the Following 1 2 3 4 5
Decadron
Dilantin
Magnesium Sulfate
Phenobarbital
Steroids
Valium
Versed
Respiratory 1 2 3 4 5
Pulmonary Resuscitation
Chest Tubes
Drawing ABG Blood Sample
Establishing an Airway
Incentive Spirometer
Interpretation of ABG
Use of IPPB / BIPAP / CPAP
Use of Pressure Support/Use of ventilator
Care of Patient With 1 2 3 4 5
ARDS
COPD
Tracheostomy
Inhalation Injuries
Pneumonia
Pre/Post Thoracic Surgery
Acute Respiratory Distress
Pulmonary Embolism
Use and Administration of the Following 1 2 3 4 5
Alupent
Aminophylline
Bronkosol
Corticosteroids
Ventolin
Transplants 1 2 3 4 5
Renal
Heart
Lung
Vascular 1 2 3 4 5
Administration of Blood & Blood Products
Air Occlusive Dressing
Assist with IV Cutdown
Fluid Overload
Heparin Drip (Precautions & Maintenance)
Hickman / Broviac / Groshong Catheters
PICC Line
Infusion Pumps
Knowledge of Normal Serum Lab Values
Maintenance of Heparin Lock
Peripheral Pulses
Starting IV's / Phlebotomy
Subcutaneous Central Line
TPN / Hyperalimentation
Ultrasonic Doppler
Other 1 2 3 4 5
Oncology
Chemotherapy
Isolation Techniques
Diabetic Teaching
Hyperbaric Oxgenation
Accucheck
Septic Shock
AIDS
Burn Care

Security Code *