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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