United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

**** ****** ****** #***

San Jose, CA 95131

This self evaluation is for assessing your experience in specific clinical areas. This self evaluation will not be a determining factor in accepting your application to become an employee of Fusion Medical Staffing.

o 0 = Not Applicable

o 1 = No Experience

o 2 = Some Experience

o 3 = Intermittent Experience

o 4 = Experienced

o 5 = Very Experienced

*Required fields

SKILL 0 1 2 3 4 5

Assist with Admission of Patient*

Assist with Ambulation*

Assist with bedpan/urinal/commode*

Backrubs/ Back care*

Basic Medical Asepsis*

Bathing: Complete/Partial/Sitz*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Bed Cradles*

Bed Making- occupied/unoccupied/surgical*

Bed Rails: when/how to use them*

Cast Care*

Charting/ Checklist/Graphic Charts*

Compresses: Warm/ Cold*

Coughing/ deep breathing*

CPR*

Crutch Walking: Assist Patient*

Dangling Patient*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Diabetic Testing*

Dietary Restrictions*

Documentation: vital signs, I & O*

Documentation of Patient’s Belongings*

Douches*

Elastic Stockings (AE hose)*

Elimination Check & Record*

Enemas, Rectal Tubes, Harris Flush*

Fall Precautions*

Feed Patient*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Foley Catheter Care & Emptying*

Footboard*

Glucometer*

Hand Hygiene*

Height: Measure & Record*

Intake & Output Measure & Record*

Orthostatic Blood Pressure*

Transfers*

Use of Assistive Devices*

Vital Signs*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Weight: Measure and Record*

Electronic Documentation

List Types:

Electronic Documentation

List Types:

Electronic Documentation

List Types:

SPECIMEN COLLECTION 0 1 2 3 4 5

Routine Urine*

Clean Catch*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

12 & 24- hour Specimen*

Stool*

Culture*

Sputum*

From Foley Catheter*

INFECTION CONTROL

PRECAUTIONS

0 1 2 3 4 5

Standard Universal Precautions*

Reverse Isolation*

TB / Airborne Precautions*

MRSA / VRE Precautions*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Nourishment for Patients*

Observing Patients*

Oral Hygiene*

Patient Safety Standards/Precautions*

Perineal Care*

Positioning Patients*

Prosthetic Devices (care of dentures, contact lenses, etc)*

Range of Motion Exercises*

Reporting Changes of Patient Condition*

Reporting/ Recording of Patient’s Pain Level*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Restraints*

Skin Care*

Application Agreement*

I certify that the information provided above accurately reflects education received and my experience in each of the clinical areas identified within the last 2 years.

The information I have given is true and accurate to the best of my knowledge, and I hereby authorize Fusion Medical Staffing to release this Skills Checklist to staffing clients of Fusion Medical Staffing. Submit this skills evaluation with your initial application. To be updated annually. Signature*

Date*

06/04/201Date Format: MM slash DD slash YYYY

First Name*

Last Name*

Category*

Select a Category*

United Health Care Staffing

www.uhcstaffing.com

Main: 408-***-****

Fax: 408-***-****

1172 Murphy Avenue #227

San Jose, CA 95131

Specialty*

Select a Specialty*

Applicant Email*

Applicant Phone*

Contact this candidate