Proﬁciency Scale:

1 – Have Done Many Times

2 – Have Done Few Times

3 – Need More Experience

4 – Have Never Done

X-Ray Equipment:

1

2

3

4

Intraoral

Cone – long and short

Digital

Panorex/Panoramic

Dental Equipment:

1

2

3

4

Lathes

Handpiece

Autoclave

Ultrasonic

Plasma Arc Light

Sterilization

Fabricate and Cement Temporary Crowns:

1

2

3

4

Remove Cement, with or without supervision

Recement, with or without supervision

Customize Temporary Crown

Coronal Polishing

Pre-Op Instructions

Post-Op Instructions

Vital Signs

Please list any additional skills/training/equipment:

Skills:

Training

Equipment:

I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. 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:

X-Ray Procedures:

X-Ray Equipment:

Pour/Trim Models:

Dental Equipment:

Anesthetic Procedures/Equipment:

Fabricate and Cement Temporary Crowns:

Insurance Billing:

Please list any additional skills/training/equipment: