Proﬁciency Scale:

1 – Perform without assistance

2 – Require some assistance

3 – Require considerable assistance

4 – No experience

GYNECOLOGY

1

2

3

4

Caesarean Section

D & C

Hysterectomy (abdo)

Hysterectomy (vag)

Laparoscopy

Tubal Reconstruction

E.N.T.

1

2

3

4

Caldwell Luc

Laryngectomy

Mastoidectomy

Radical Neck

Ts and As

ORTHOPAEDIC

1

2

3

4

Amputation of limb

Arthroscopy

Appl. external fix.

Hip replacement

ORIF of fractures

Spinal fusion

Insertion Spinal Rods

PLASTICS

1

2

3

4

Reduction Mammoplasty

Rhinoplasty

Scar Revisions

Skin grafts

THORACIC

1

2

3

4

Chest Tube Insertion

Hiatal Hernia

Lobectomy

Pneumectomy

ANAESTHETICS

1

2

3

4

Familiar with Boyles Machine

Machine

Arterial / CVP set up

Please indicate the number of years experience in each:

EXPERIENCE LEVELS =: C = Circulate / S = Scrub / B = Both / N = Neither

Experience Levels	Value
Circulate
Scrub
Adult
Pediatric
Both

Personal Objections to	Yes/No
Therapeutic Abortions
Salpingectomies

Additional Skills

Qualifications

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:

GENERAL SURGERY

GYNECOLOGY

G.U.

E.N.T.

CARDIO-VASCULAR

ORTHOPAEDIC

NEUROSURGERY

PLASTICS

OPTHALMIC

THORACIC

ENDOSCOPY

ANAESTHETICS

Please indicate the number of years experience in each:

EXPERIENCE LEVELS =: C = Circulate / S = Scrub / B = Both / N = Neither