Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
INTERPRETATIVE SKILLS
Pap (GYN) 0 1 2
Conventional 0 1 2
Thin-prep 0 1 2
Autocyte 0 1 2
Non-GYN 0 1 2
Bronchs 0 1 2
Sputa 0 1 2
BAL 0 1 2
Body fluids 0 1 2
FNA 0 1 2
General 0 1 2
Breast 0 1 2
Lung 0 1 2
Nodes 0 1 2
Other 0 1 2
OTHER SKILLS
Computer literacy 0 1 2
Automated equipment 0 1 2
Cytospin 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(Birth - 1 Year) B= Pediatric/Adolescent(1-18 Yrs) C=Adultt(19-64 Yrs) D=Geriatric(65 + Yrs)
A
B
C
D
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminologyf patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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