Personal Information

*Please fill the email ID correctly for successful submission

Proﬁciency Scale:

1 – Limited or no experience

2 – Experienced, but may need review or supervision

3 – Able to function independently

SCRUB: ENDOVASCULAR EXPERIENCE:

Endoluminal AAA

Carotid revascularization endarterectomy

Cerebral aneurysm repair

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:

WORK EXPERIENCE

GENERAL SKILLS EXPERIENCE

SCRUB: GENERAL SURGERY EXPERIENCE:

SCRUB: GYNECOLOGY EXPERIENCE

SCRUB: ENDOSCOPIC PROCEDURES EXPERIENCE

SCRUB: LAPAROSCOPIC PROCEDURES EXPERIENCE

SCRUB: UROLOGY EXPERIENCE:

SCRUB: ORTHOPEDIC EXPERIENCE:

SCRUB: NEUROLOGY EXPERIENCE

SCRUB: PLASTICS EXPERIENCE

SCRUB: OPHTHALMOLOGY EXPERIENCE:

SCRUB: EAR, NOSE & THROAT EXPERIENCE:

SCRUB: VASCULAR EXPERIENCE:

SCRUB: ENDOVASCULAR EXPERIENCE:

SCRUB: THORACIC / CARDIOVASCULAR EXPERIENCE:

SCRUB: TRANSPLANT EXPERIENCE:

SCRUB: TRAUMA EXPERIENCE:

SCRUB: EQUIPMENT EXPERIENCE:

SCRUB: AGE-SPECIFIC EXPERIENCE: