Personal Information

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Proﬁciency Scale:

1 – No experience; Theory/observed only

2 – Limited competency; < 5 times per year; Needs supervision

3 – Acceptable competency; > 5 times per year

4 – Competent; Performs on a daily or weekly basis; Proficient

Please list any areas of expertise below:

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:

Assessment

Equipment & Procedures

O2 therapy & medication delivery systems

Restraints, application and assessment of:

Care of Patients with

Medications

Phlebotomy/IV Therapy

Age Specific Practice Criteria

EMR

Please list any additional skills/training/equipment: