Sterile Processing Technologist 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

Processing	Rating Stars (Click)	1	2	3	4
Single instruments
Endoscopes
Repair
Sets/ Trays
Care of instruments
Other (list)
Decontamination	Rating Stars (Click)	1	2	3	4
Manual cleaning
Washer sterilizer
Soiled linen
Disinfectants
Sharps
Disposable items
Cleaning equipment
Detergents
Dress code
Steam Sterilization	Rating Stars (Click)	1	2	3	4
Chart recording
Chart recording
Time
Testing/ Monitoring

Tests	Rating Stars (Click)	1	2	3	4
Test control
Recording
Other (list):
Assembly andPreparation	Rating Stars (Click)	1	2	3	4
Assembly andPreparation
Wrapping materials
Autoclave tape
Dust covers
Proper towel/ linen folding
Proper labeling
Expiration dates
Packing for steam
Heat sealing
Instrument count sheets
Placing instruments on trays
Other (list):
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)