* Please note that fields marked with a * are required.
Date
* Applicant's Name: Last
Middle Initial
* First
To ArdorHealthSolutions Healthcare Professionals:
The following checklist is a profile used to assess your clinical proficiency and assist in matching your skills with available assignments. Your employment is not dependent upon responses given in this checklist. Please rate your ability as accurately as possible by checking the appropriate box.
The information I have given here is true and accurate to the best of my knowledge. In addition, I also authorize ArdorHealthSolutions to release this skills checklist to client institutions of ArdorHealthSolutions in relation to my employment with that institution.
* Signature (Please Type Full Name)
* Date
Please Mark Your Level of Experience 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 Daily or Weekly Basis; Proficient
Procedures, Assist or Knowledge of
1
2
3
4
Anoscopy
Bronchoscopy
Colonoscopy
EGD
ERCP
Flexible Sigmoidoscopy
Proper Assessment and Documentation of Conscious Sedation Record
Rigid Protoscopy
Sphincterotomy
Assessory Equipment
Cytology Brushes
Decompression Tubes
Dilators
Baloon
Maloney
Savory
Forceps
Foreign Body Equipment
Polyp Snares
Valley Lab BX
Bleeder Cart Equipment
Bicap Unit
Code Blue Lavage Kit
Endo Pump
Esophageal Banding
Gold Probe/Injector Needle
Scero Needles and Meds
Equipment and Stock
Papillatomy
Som Procedure
Stent Placement
Specimen Collection
Biopsies
Cytology
Immuno Supressed Protocol
Manometry and Diagnostic Testing
24 Hour PH Ambulatory Study
Esophogeal Manometry
Liver BX
Paracentesis
Pediatric Procedures
Pediatric Peg Cart
Proper EGD Scopes According to Age
Specific Equipment for Pediatric Scopes
Cleaning
Proper Scope Cleaning
Proper Use of Scope Washers
Storing Scopes
Use of Leak Tester
Age of Patients Cared for
Infants and Toddlers (ages 0-3 years)
Young Children (ages 4-6 years)
Older Children (ages 7-12 years)
Adolescents (ages 13-20 years)
Young Adults (ages 21-39 years)
Middle Adults (ages 40-64 years)
Older Adults (ages 65+ years)
Units Worked
Years
Outpatient Department
Freestanding Clinic
Total Number of Years
Certifications
Yes
No
Exp Date
ACLS
BCLS
IV Certification
NALS
NPR
PALS
Other
Equipment Please list any equipment not previously listed.
Additional Skills Please list any additional experience or skills not previously listed.
