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)

SKILLED ENVIRONMENTS

Acute Care/Hospital

Managed Care

SNF/Long Term Care

Home Health

Outpatient

EXPERIENCE

Reviewing Facility Policy and Procedures

Knowledge of State Protocols/Regulations

Risk Analysis

Insurance Knowledge

Vendor Relations

Identify Threats and Emerging Risk

Identify, Assess, Mitigate and Evaluate Risk

RCA Facilitation

Accreditation Survey Preparation

Please list any additional areas of expertise below:

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

SKILLED ENVIRONMENTS

GENERAL RISK/QUALITY

EXPERIENCE