Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
FIXATION
Light Microscopy 0 1 2
Electron microscopy 0 1 2
Special stains 0 1 2
Frozen sections/tissues 0 1 2
Enzyme histochemistry 0 1 2
Immunohistochemistry 0 1 2
Artifacts/precipitates/pigments 0 1 2
Quality control 0 1 2
Cytologic specimens 0 1 2
PROCESSING/EMBEDDING
Light microscopy 0 1 2
Frozen sections/tissues 0 1 2
Enzyme histochemistry 0 1 2
Calcified/decalcified tissue 0 1 2
Immunohistochemistry 0 1 2
Quailty control 0 1 2
Cytologic specimens 0 1 2
MICROTOMY
Paraffin 0 1 2
Frozen section 0 1 2
Agar/gelatin 0 1 2
Quality control 0 1 2
STAINING
Nucleus/cytoplasma (e.g. H&E) 0 1 2
Blood/bone marrow 0 1 2
Carbohydrates 0 1 2
Connective/supporting tissue 0 1 2
Lipids 0 1 2
Microorganisma 0 1 2
Nerve 0 1 2
Pigments/minerals/granules 0 1 2
Quality control 0 1 2
Do you have MOHS experience? No Yes

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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