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)

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 Electronic Documentation:

Other Electronic Documentation- IV Pumps

Other Electronic Documentation- Other IV Pumps

ENVIRONMENTS

MANAGEMENT