Personal Information

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Proficiency Scale

1: No experience

2: Need Training

3: Able to perform with supervision

4: Able to perform independently

Age Specific Competency

Able to ensure a safe and caring environment for the specific age groups indicated below; able to communicate and instruct patients from various age groups; able to evaluate age-appropriate behavior and skills.

The information represented above is true and correct to the best of my knowledge. I also authorize Tricehealthcare to share the above skills checklist with its hospital clients

I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Proficiency Scale

Assessment of:

Equipment and Procedures:

Monitoring / telemetry:

BASIC INFECTION CONTROL PROCEDURE

Pacemaker:

Pain management:

Care of patients with:

Administration of:

Age Specific Competency

Age Specific Competency