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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