RN-Occupational and Employee Health 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

TRAUMA	Rating Stars (Click)	1	2	3	4
Care of Patient with:
Minor Trauma
Major Trauma
MAST Suit
BURNS	Rating Stars (Click)	1	2	3	4
Care of Patient with:
First Degree
Second Degree
Third Degree
Electrocution
Hazardous Materials Exposure
LACERATIONS	Rating Stars (Click)	1	2	3	4
Care of Patient with:
Assessment
Cleansing
Steri-Strips
Dressing
SPRAIN/STRAIN	Rating Stars (Click)	1	2	3	4
Assessment
Carpal Tunnel
Tendonitis
Epicondylitis
PHYSICALS	Rating Stars (Click)	1	2	3	4
Safety
Return to Work
Respirator
Vital Signs
Height/Weight
Blood Draw
Medical Referral Form
Medical Certification Form
Medical History Questionnaire
Potassium Iodine Assessment
RESTRICTIONS	Rating Stars (Click)	1	2	3	4
Temporary Restrictions
Permanent Restrictions
Pulmonary Function
Audiometry
Vision Testing
X-ray
Urine Testing
Drug Testing
Breathalyzer
IMMUNIZATIONS	Rating Stars (Click)	1	2	3	4
Havrix (Hepatitis A)
Influenza Vaccine
Meningitis Vaccine
Tetanus & Diphtheria
Oral Typhoid Vaccine
Polio Vaccine
Hepatitis B Vaccine
Japanese Encephalitis B
Rabies Vaccine
Typhim (Injectable Type)
Yellow Fever Vaccine
Age Specific Criteria	Rating Stars (Click)	1	2	3	4
Newborn/Neonate (birth-30 days)
Infant (30 days - 1 year)
Toddler (1-3 years)
Preschooler (3-5 years)
School Age Children (5-12 years)
Adolescents (12-18 years)
Adolescents (12-18 years)
Young Adults (18-39 years)
Middle Adults (39-64 years)
Older Adults (64+)