Please rate your level of experience:

    1. 1. No Experience: Observed Only
    2. 2. Limited Experience: Performs < 6 Times Per Year (needs review)
    3. 3. Moderate Experience: Performs 1-2 Times Per Month; May Need Minimal Resource
    4. 4. Highly Experienced: Performs on a Daily or Weekly Basis; Proficient
    A - Medication Administration

    B - Phlebotomy/IV Therapy


    C - Patients with Cardiovascular Problems


    D - Respiratory


    E - Patients with Neurological Problems


    F - Patients with Wounds/Skin Problems

    G - Patients with Endocrine Problems


    H - Patients with Renal/GU Problems

    I - Patients with Gastrointestinal Problems

    J - Patients with Orthopedic Problems

    K - Additional Medical-Surgical Skills

    L - Age of Patients Cared For


    Personal Information




    The information I have given is true & accurate to the best of my knowledge. In addition, I hereby authorize Horizons Healthcare Agency to release this Skills Checklist to client institutions, in relation to my employment with that institution.


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