Infection Control Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Surveillance	Rating Stars (Click)	1	2	3	4
�Performs targeted surveillance
Outbreak investigations
Collaboration� with Infection Control Committee
Collaboration with Hospital Epidemiologist
Performance improvement projects related in communicable diseases
Collects
monitors
and maintains data using� facility HER
Utilize Center for Disease Control (CDC)
Infection criteria
�TB
AIDS
Documentation and investigation techniques
Rounds of hospital units
Case definition
and other related patient care issues
Monitor� infection control practices
Nosocomial infections� or AHIs
MRSAs
Health care workers exposures
Tracing the possible sources of infection or transmission of microorganisms
Identification of Problems	Rating Stars (Click)	1	2	3	4
Regularly meet with the hospital Epidemiologist
Risk� reduction among patients
facility staff
volunteers
students
and visitors
Understand the transmission and break of infections
Identification of epidemiologically important issues for Infection Control Committee
Hospital Epidemiologist, and Administration	Rating Stars (Click)	1	2	3	4
Design COA� including Surveillance
Outbreak Investigations
and Performance Improvement Projects
Communicable diseases reporting as required by the state and the local health authority
Compliance with federal and state laws regarding� medical wastes
chemicals in the workplace
infectious disease exposures
OSHA NIOSH standards
Blood borne pathogens and respiratory pathogens
Chart review
Policies and Procedures	Rating Stars (Click)	1	2	3	4
Infection Control policies associated with infection
Staff practices associated with infection contol
Professional guidelines (CDC
APIC
etc.)
The Joint Commission guidelines on infection Control
Infection Control Plan to reflect and meet any required changes
Coordination	Rating Stars (Click)	1	2	3	4
Acts as department liaison for Infection Control Department
Act as consultant for the facility Infection Control activities
Interdepartment and personnel coordination on risk� reduction
transmission and improved infection control practices
Provide coordinated services to patients for the improvement of overall
Patient care
Education	Rating Stars (Click)	1	2	3	4
In-services of all and current employees� on Infection Control
Orientation programs of new employees on Infection Control
Infection Control techniques and Policies and Procedures
Age Specific Competencies	Rating Stars (Click)	1	2	3	4
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)