Personal Information

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Proﬁciency Scale:

1 – No experience; Theory/observed only

2 – Intermittent experience; < 5 times per year; Needs review

3 – Moderate experience; > 5 times per year; May need minimal resource

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

E.N.T.

Middle Ear Cases

T&A

Myringotomy

Tympanoplasty

Radical Neck Dissection

Septoplasty

Sinus Endoscopy

Vascular Surgery

Carotid Endarterectomy

Abdominal Aortic Aneurysm

Femoral- Popliteal By-pass Graft (Insitu)

Femoral- Popliteal By-pass Graft (Graph)

Portacath, Tesio, Hickman Placement

AV Shunt

Thrombectomy

Pacemaker Insertion

Arterial Stenting

Intra-Operative Angioplasty

Subclavin / Carotid By-pass

Urology

Radical Prostatectomy

Radical Lymph Node Dissection

Ureteroscopy

TURP / TURST

Ultrasonic Lithotripsy

Hydrocelectomy

Cystoscopy

Insertion Penile Prosthesis

Neurology

Cervical Laminectomy (Anterior)

Cervical Laminectomy (Posterior)

Lumbar Laminectomy Discectomy

Percutaneous Micro Discectomy

Craniotomy For Tumor

Craniotomy For Aneurysm

Burr Holes

VP Shunts

Transphenoidal Hypothypectomy

Carpal Tunnel Repair

Harrington Rod or Similar

Plastics

Mammoplasty

Facelifts

Skin Grafts

Rhinoplasty

Cleft Lip Repair

Abdominalplasty

Blepharoplasty

Otoplasty

Muscle Flaps

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

E.N.T.

Cardiac / Thoracic / Vascular

Vascular Surgery

Orthopedics

Urology

Gynecology

Neurology

Trauma Surgery

Plastics