Personal Information

*Please fill the email ID correctly for successful submission

Proﬁciency Scale:

0 = No Experience / Observed Only

1 = Limited Experience / Rarely Done (6 times/year)

2 = May Need Some Review / Occasionally Done (1 – 2 times/month)

3 = Experienced / Frequently Done (daily or weekly)

Automated Med Dispensing Systems (Check all that applies)

Accudose Metro Omnicell Promanager Rx Pyxis N/A

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:

AGE OF PATIENTS CARED FOR

GENERAL SKILLS

MEDICATION ADMINISTRATION

PRE-PROCEDURE

PROCEDURES/EQUIPMENT

POST-PROCEDURE

Automated Med Dispensing Systems (Check all that applies)

Electronic Documentation (Check all that applies)

IV Pumps (Check all that applies)