Skills Assessment - Operating Room RN
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The following checklist will be used to match your skills and interests with available assignments.
Please enter your information, and we will store this information with your application/profile.
Please indicate your level of proficiency by marking the appropriate number.
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First Name:
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Middle Initial:
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Last Name:
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SSN:
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-
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E-mail Address:
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Home Phone:
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-
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Work Phone:
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-
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Cell Phone:
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-
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City:
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State:
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0. Theory, no practice 1. Limited 2. Confident 3. Very Confident
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Scrub - Ear, Nose, & Throat:
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Experience:
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Caldwell - Luc
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0
1
2
3
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Laryngectomy
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0
1
2
3
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Cleft lip/palate repair
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0
1
2
3
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Radical neck dissection
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0
1
2
3
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T&A
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0
1
2
3
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Scrub - General Surgery:
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Bronchoscopy
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0
1
2
3
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Appendectomy
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0
1
2
3
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Laparoscopic Appendectomy
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0
1
2
3
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Cholecystectomy
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0
1
2
3
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Laparoscopic Cholecystectomy
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0
1
2
3
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Hernia Repair
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0
1
2
3
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Laparoscopic Hernia Repair
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0
1
2
3
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Colon Resection
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0
1
2
3
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Rectal Surgery
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0
1
2
3
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Pancreatectomy
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0
1
2
3
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Splenectomy
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0
1
2
3
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Thyroidectomy
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0
1
2
3
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Vein Stripping
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0
1
2
3
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Whipple Procedure
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0
1
2
3
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Abdominal Perineal Resection
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0
1
2
3
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Scrub - Gynecology:
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Hysterectomy, abdominal
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0
1
2
3
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Hysterectomy, vaginal
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0
1
2
3
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Tubal ligation
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0
1
2
3
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Tuboplasty
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0
1
2
3
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Anterior posterior repair
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0
1
2
3
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Scrub - Neurosurgery:
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Craniotomy for Tumor
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0
1
2
3
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Craniotomy for Aneurysm
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0
1
2
3
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Ventricular Peritoneal Shunt
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0
1
2
3
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Lumbar Laminectomy
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0
1
2
3
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Cervical Laminectomy
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0
1
2
3
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Posterior Sitting Laminectomy
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0
1
2
3
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Transsphenoidal Hypophysectomy
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0
1
2
3
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Ulnar Nerve Transposition
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0
1
2
3
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Scrub - Opthalmology:
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Cataract extraction with IOL
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0
1
2
3
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Corneal transplant
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0
1
2
3
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Scleral Buckling
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0
1
2
3
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Scrub - Orthopedics:
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Ankle Surgery
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0
1
2
3
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Hand/Micro Hand Surgery
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0
1
2
3
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Hip Prosthesis
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0
1
2
3
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Knowles Pinning
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0
1
2
3
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Spinal Fusion
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0
1
2
3
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ACL Repair
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0
1
2
3
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Shoulder Surgery
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0
1
2
3
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Total Knee Surgery
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0
1
2
3
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Total Hip Replacement
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0
1
2
3
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ORIF
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0
1
2
3
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Scrub - Plastics:
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Liposuction
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0
1
2
3
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Rhinoplasty
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0
1
2
3
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Face Lift
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0
1
2
3
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Skin Graft
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0
1
2
3
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Breast Reconstruction
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0
1
2
3
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Breast Reduction
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0
1
2
3
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Cleft lip/palate repair
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0
1
2
3
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Free/TRAM Flap
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0
1
2
3
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Scrub - Thoracic & Open Heart:
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Open Heart Bypass
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0
1
2
3
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Open Heart Valve Replacement
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0
1
2
3
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Aortic Aneurysm Repair
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0
1
2
3
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Thoracotomy
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0
1
2
3
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Lung Resection
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0
1
2
3
|
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Pneumonectomy
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0
1
2
3
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Scrub - Urology:
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Cystectomy
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0
1
2
3
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Kidney Transplant
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0
1
2
3
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Percutaneous Nephrolithotomy
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0
1
2
3
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Nephrectomy
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0
1
2
3
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Prostatectomy
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0
1
2
3
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TURP
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0
1
2
3
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Ureterolithotomy
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0
1
2
3
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Vasectomy
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0
1
2
3
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Scrub - Vascular:
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A-V access graft
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0
1
2
3
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Carotid Endarterectomy
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0
1
2
3
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Peripheral vascular bypass procedures
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0
1
2
3
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Thrombectomy/embolectomy
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0
1
2
3
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Vena cava filter/umbrella
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0
1
2
3
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Vena cava ligation
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0
1
2
3
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| |
| |
|
Circulate - Ear, Nose, & Throat:
|
Experience:
|
|
Caldwell - Luc
|
0
1
2
3
|
|
Laryngectomy
|
0
1
2
3
|
|
Cleft lip/palate repair
|
0
1
2
3
|
|
Radical neck dissection
|
0
1
2
3
|
|
T & A
|
0
1
2
3
|
| |
|
Circulate - General Surgery:
|
|
Bronchoscopy
|
0
1
2
3
|
|
Appendectomy
|
0
1
2
3
|
|
Laparoscopic Appendectomy
|
0
1
2
3
|
|
Cholecystectomy
|
0
1
2
3
|
|
Laparoscopic Cholecystectomy
|
0
1
2
3
|
|
Hernia Repair
|
0
1
2
3
|
|
Laparoscopic Hernia Repair
|
0
1
2
3
|
|
Colon Resection
|
0
1
2
3
|
|
Rectal Surgery
|
0
1
2
3
|
|
Pancreatectomy
|
0
1
2
3
|
|
Splenectomy
|
0
1
2
3
|
|
Thyroidectomy
|
0
1
2
3
|
|
Vein Stripping
|
0
1
2
3
|
|
Whipple Procedure
|
0
1
2
3
|
|
Abdominal Perineal Resection
|
0
1
2
3
|
| |
|
Circulate - Gynecology:
|
|
Hysterectomy, abdominal
|
0
1
2
3
|
|
Hysterectomy, vaginal
|
0
1
2
3
|
|
Tubal ligation
|
0
1
2
3
|
|
Tuboplasty
|
0
1
2
3
|
|
Anterior posterior repair
|
0
1
2
3
|
| |
|
Circulate - Neurosurgery:
|
|
Craniotomy for Tumor
|
0
1
2
3
|
|
Craniotomy for Aneurysm
|
0
1
2
3
|
|
Ventricular Peritoneal Shunt
|
0
1
2
3
|
|
Lumbar Laminectomy
|
0
1
2
3
|
|
Cervical Laminectomy
|
0
1
2
3
|
|
Posterior Sitting Laminectomy
|
0
1
2
3
|
|
Transsphenoidal Hypophysectomy
|
0
1
2
3
|
|
Ulnar Nerve Transposition
|
0
1
2
3
|
| |
|
Circulate - Opthalmology:
|
|
Cataract extraction with IOL
|
0
1
2
3
|
|
Corneal transplant
|
0
1
2
3
|
|
Scleral Buckling
|
0
1
2
3
|
| |
|
Circulate - Orthopedics:
|
|
Ankle Surgery
|
0
1
2
3
|
|
Hand/Micro Hand Surgery
|
0
1
2
3
|
|
Hip Prosthesis
|
0
1
2
3
|
|
Knowles Pinning
|
0
1
2
3
|
|
Spinal Fusion
|
0
1
2
3
|
|
ACL Repair
|
0
1
2
3
|
|
Shoulder Surgery
|
0
1
2
3
|
|
Total Knee Surgery
|
0
1
2
3
|
|
Total Hip Replacement
|
0
1
2
3
|
|
ORIF
|
0
1
2
3
|
| |
|
Circulate - Plastics:
|
|
Liposuction
|
0
1
2
3
|
|
Rhinoplasty
|
0
1
2
3
|
|
Face Lift
|
0
1
2
3
|
|
Skin Graft
|
0
1
2
3
|
|
Breast Reconstruction
|
0
1
2
3
|
|
Breast Reduction
|
0
1
2
3
|
|
Cleft lip/palate repair
|
0
1
2
3
|
|
Free/TRAM Flap
|
0
1
2
3
|
| |
|
Circulate - Thoracic & Open Heart:
|
|
Open Heart Bypass
|
0
1
2
3
|
|
Open Heart Valve Replacement
|
0
1
2
3
|
|
Aortic Aneurysm Repair
|
0
1
2
3
|
|
Thoracotomy
|
0
1
2
3
|
|
Lung Resection
|
0
1
2
3
|
|
Pneumonectomy
|
0
1
2
3
|
| |
|
Circulate - Urology:
|
|
Cystectomy
|
0
1
2
3
|
|
Kidney Transplant
|
0
1
2
3
|
|
Percutaneous Nephrolithotomy
|
0
1
2
3
|
|
Nephrectomy
|
0
1
2
3
|
|
Prostatectomy
|
0
1
2
3
|
|
TURP
|
0
1
2
3
|
|
Ureterolithotomy
|
0
1
2
3
|
|
Vasectomy
|
0
1
2
3
|
| |
|
Circulate - Vascular:
|
|
A-V access graft
|
0
1
2
3
|
|
Carotid Endarterectomy
|
0
1
2
3
|
|
Peripheral vascular bypass procedures
|
0
1
2
3
|
|
Thrombectomy/embolectomy
|
0
1
2
3
|
|
Vena cava filter/umbrella
|
0
1
2
3
|
|
Vena cava ligation
|
0
1
2
3
|
| |
|
Circulate - Equipment:
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Argon beam coagulator
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0
1
2
3
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Bair Hugger
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0
1
2
3
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Blood/fluid warmer
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0
1
2
3
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Cell saver
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0
1
2
3
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Use of Cavitron machine
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0
1
2
3
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Lasers
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0
1
2
3
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Pleur-evac disposable chest drainage
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0
1
2
3
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Steri-vac aeration cabinet, 3-M, portable
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0
1
2
3
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Steris unit
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0
1
2
3
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Suction unit, disposable
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0
1
2
3
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Washer sanitizer - AMSCO
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0
1
2
3
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Washer sterilizer - AMSCO
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0
1
2
3
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Circulate - Phlebotomy/IV Therapy:
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Administration of blood/
blood products
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0
1
2
3
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Drawing blood from central line
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0
1
2
3
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Starting IVs with Angiocath
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0
1
2
3
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Age-Specific Practice Criteria:
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Please check the box corresponding to each
age group for which you have expertise in
providing age-appropriate nursing care.
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Pediatric (1 - 12years)
Adolescents (12 - 18 years)
Adult (19 - 65 years)
Older Adult (Older than 65 years)
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Experience With Age Groups:
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Calculate body weight to verify correct dosing of medication
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0
1
2
3
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Assess immunization status for pediatric, and adolescent
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0
1
2
3
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Set age-appropriate short-term and long-term goals in care planning
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0
1
2
3
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Provide age-appropriate education, considering possible vision and hearing impairment for older than 65 years
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0
1
2
3
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