* Please note that fields marked with a * are required.
Date
* Applicant's Name: Last
* First
Middle Initial
Profession RRT CRTT
Registry Eligible Yes No
Please Mark Your Level of Experience 1 - No Experience 2 - Limited Experience (Assistance Needed) 3 - Some Experience (Needs Resource for Backup) 4 - Very Experienced (Requires No Supervision)
Work Settings
1
2
3
4
Emergency Room
Intensive Care Unit ICU
Coronary Care Unit CCU
Skilled Nursing Homes
Level I Nursery
NICU Level II
NICU Level III
Pediatrics
PICU
Pulmonary Rehabilitation
Home Care
Sleep Lab
Floor Therapy
Burn Unit
Medications
Albuterol (Proventil)
Atrovent Alupent
Ribaviran
Vanceril
Intal (Cromlyn-Sodium)
Combivent
Dopamine
D-Nase
Morphine Sulfate
Pentamidine
Pavulon
Steroids
Tobramyein
Racemic Ephinephrine (Vaponefrin)
Other
Specific Skills
ABG's
Radial Artery
Branchial Artery
Femoral Artery
Arterial Line
ABG Interpretation
Pulmonary Stress Testing
Intubate Adult
Intubate Infants
Attend High Risk Delivery
Pulmonary Function Testing (PFT)
Flow Volume Loop
VD/VT Ratio
Mechanics
Negative Inspiratory Force
Vital Capacity
Ability to:
Ventilate Patient with manual Resuscitator
Check Intracuff Pressure
Troubleshooting Ventilators
Knowledge of Chest Tubes
Documentation Skills
Trach Care
EEG
EKG
Assist with Bronchoscopies
SPAG Unit
Basic Respiratory Therapy
Nasal O-2 Setup
Venturi
Simple Mask
Nonrebreathing Mask
Nebulizers
Heated
Cold
Ultrasonic Nebulizers
Aerosol Set-Up for Trach Patients
Trach Masks
T-Piece
Aerosol for Medication
Hand Held Nebulizers
Acorn Nebulizers
Incentive Spirometry
IPPB Treatments
AP5
Bird
Medihalers/Metered Dose Inhalers
Chest Physical Therapy
Percussion, Vibration & Postural Drainage
IPV
Flutter
Therapy Vest
Infant Hood Set-up
Ventilators
BiPap (Non-Invasive Ventilation)
LP6, LP10 Ventilator
Nitrous Oxide Delivery
PDP's (Pathways/Protocols)
Puritan Bennet 7200
Siemens Servo 900B, 900C, 300
Newport Wave, E100i
Bear Model Number
HME
Closed Circuit Suction
Puritan Bennet 80
Age of Patients
Neo-Natal (Up to 1 Month)
Infant (1 Month to 1 Year)
Pediatric (1 to 12 Years)
Adolescent (12 to 18 Years)
Adult (18 to 65 years)
Geriatric (65 Years +)
Additional Skills / Certifications Please list any aditional experience or skills that have not been included above:
* Signature (Please Type Full Name)
* Date
