Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
IV THERAPY
Start peripheral IV - angio cath S C 0 1 2
IV THERAPY - Assist with:
Insertion of A-lines S C 0 1 2
Insertion of CVP - jugular S C 0 1 2
Insertion of CVP - subclavian S C 0 1 2
Insertion of Swan-Ganz S C 0 1 2
Drawing of blood from central line S C 0 1 2
Drawing venous blood S C 0 1 2
ADMINISTRATION OF BLOOD & PRODUCTS
Packed red blood cells S C 0 1 2
Plasma/Albumin S C 0 1 2
Whole blood S C 0 1 2
GENERAL SURGERY
Abdominal perineal resection S C 0 1 2
Adrenalectomy S C 0 1 2
Anal fissurectomy S C 0 1 2
Appendectomy S C 0 1 2
Bowel resection S C 0 1 2
Breast biopsy S C 0 1 2
Cholecystectomy (open) S C 0 1 2
Colectomy S C 0 1 2
Colostomy/ileostomy S C 0 1 2
Esophogeal resection S C 0 1 2
Exploratory laparotomy S C 0 1 2
Gastrectomy S C 0 1 2
Gastroplasty S C 0 1 2
Hemorrhoidectomy S C 0 1 2
Hemicolectomy S C 0 1 2
Hepatic resection S C 0 1 2
Herniorrhaphy - femoral S C 0 1 2
Herniorrhaphy - inguinal S C 0 1 2
Herniorrhaphy - umbilical S C 0 1 2
Herniorrhaphyhiatal S C 0 1 2
Transabdominal/transthoracic S C 0 1 2
Hiatal hernia repair S C 0 1 2
Hepatic - resection S C 0 1 2
Insertion - Hickman S C 0 1 2
Insertion - Groshong S C 0 1 2
Insertion - Portacath S C 0 1 2
Hydrocelectomy S C 0 1 2
GENERAL SURGERY (C0NT)
Imperforate anus reconstruction S C 0 1 2
Lumbar sympathectomy S C 0 1 2
Omphalocele repair S C 0 1 2
Pancreatectomy/pancreatogram S C 0 1 2
Pilonidal cystectomy S C 0 1 2
Portal caval shunt S C 0 1 2
Pyloric stenosis S C 0 1 2
Radical mastectomy S C 0 1 2
Saphenous vein ligation & stripping S C 0 1 2
Sentinel node biopsy S C 0 1 2
Splenectomy S C 0 1 2
Tenchknoff duct cyst excision S C 0 1 2
Thyroglossal duct cyst excision S C 0 1 2
Thryoidectomy S C 0 1 2
Vagotomy S C 0 1 2
THORACIC & OPEN HEART
Cervical rib excision S C 0 1 2
Chamberlain procedure S C 0 1 2
Closed thoracotomy S C 0 1 2
Correction pectus excavatum S C 0 1 2
Esophagectomy S C 0 1 2
Heller procedure S C 0 1 2
Mitral commissurotomy S C 0 1 2
Mitral or aortic valve replacement S C 0 1 2
IAPB insertin S C 0 1 2
CABG S C 0 1 2
Cardiac valve replacement S C 0 1 2
Patent ductus arteriosus repair S C 0 1 2
Septal defect repairs S C 0 1 2
Pacemaker implantation-endocardial S C 0 1 2
Pacemaker implantation-myocardial S C 0 1 2
Pacemaker-temporary S C 0 1 2
Pericardiectomy S C 0 1 2
Pericardial window S C 0 1 2
Resection coarctation aorta S C 0 1 2
Portocaval shunt S C 0 1 2
Tetrology of fallot S C 0 1 2
Thoracoplasty S C 0 1 2
THORACIC & OPEN HEART
Tracheal resection S C 0 1 2
Transthoracic diaphragmatic
heniorrhaphy S C 0 1 2
VASCULAR
A-V access graft S C 0 1 2
Aortic aneurysm with graft
replacement S C 0 1 2
Endarterectomy/carotid-femoral S C 0 1 2
Fem-pop bypass S C 0 1 2
Peripheral vascular bypass
procedures S C 0 1 2
Resection carotid aneurysm
with graft S C 0 1 2
Thrombectomy/embolectomy S C 0 1 2
Vena cava filter/umbrella S C 0 1 2
Vena cava ligation S C 0 1 2
NEUROLOGY
A-V malformation S C 0 1 2
Anterior cervical fusion S C 0 1 2
Anterior laparoscopic spine
procedures S C 0 1 2
Anterior lumbar interody fusion (ALIF) S C 0 1 2
Burr holes for subdural hematoma S C 0 1 2
Carotid ligation S C 0 1 2
Cervical sympathectomy S C 0 1 2
Craniectomy for decompression
fracture S C 0 1 2
Disectomy S C 0 1 2
Hypophysectomy S C 0 1 2
Insertion nerve stimulators S C 0 1 2
Insertion medication pumps S C 0 1 2
Laminectomy S C 0 1 2
Myelomeningocele S C 0 1 2
Pedicle screw insertion S C 0 1 2
Posterior lumbar interbody fusion (PLIF) S C 0 1 2
Shunt procedure/VP, VA/LP S C 0 1 2
Spine fusion S C 0 1 2
Ulnar nerve transfer S C 0 1 2
NEUROLOGY (C0NT)
Ventriculography/ventriculoscopy S C 0 1 2
Ventriculostomy S C 0 1 2
Cranioplasty/Craniotomy
Clipping of aneurysm S C 0 1 2
Tumor excision S C 0 1 2
Stealth crainiotomy S C 0 1 2
UROLOGY
Adult circumcision S C 0 1 2
Cystectomy S C 0 1 2
Cystoscopy/ureteroscopy S C 0 1 2
Hypospadias repair S C 0 1 2
Illeal loop S C 0 1 2
Implants-penile & testicular S C 0 1 2
Lithotripsy S C 0 1 2
Nephrectomy S C 0 1 2
Nephrolithotomy S C 0 1 2
Orchiopexy S C 0 1 2
Prostatectomy- perineal S C 0 1 2
Prostatectomy-supra-pubic S C 0 1 2
Pyleoplasty S C 0 1 2
Radical node dissection S C 0 1 2
Scott incontinence device S C 0 1 2
TURP S C 0 1 2
Ureterolithotomy S C 0 1 2
Vasectomy S C 0 1 2
Vasovasostomy S C 0 1 2
Waterhouse procedure S C 0 1 2
GYNECOLOGY
Cesarean section S C 0 1 2
Colpotomy S C 0 1 2
Dilation & curettage (D&C) S C 0 1 2
Hysterectomy-abdominal S C 0 1 2
Hysterectomy-vaginal S C 0 1 2
Marshall-Marchetti S C 0 1 2
Marsupialization, Bartholin cyst S C 0 1 2
Ovarian cystectomy S C 0 1 2
Radium insertion S C 0 1 2
Salpingo-oophorectomy S C 0 1 2
Sacral spinus fization S C 0 1 2
Shirodkar procedure S C 0 1 2
Suction curettage S C 0 1 2
GYNECOLOGY (C0NT)
Termination of pregnancy S C 0 1 2
Tubal ligation S C 0 1 2
Vaginal reconstruction S C 0 1 2
Vaginectomy/vulvectomy S C 0 1 2
ORTHOPEDICS
Acetabular/pelvic ORIF S C 0 1 2
Achilles tendon repair S C 0 1 2
Amputation-leg, arm S C 0 1 2
Anterior cruciate ligament repair S C 0 1 2
Application of external
fixators-extremities S C 0 1 2
Application of external
fixators-pelvis S C 0 1 2
Application of halo traction S C 0 1 2
Arthrotomy S C 0 1 2
Bipolar/unipolar hips S C 0 1 2
Bunionectomy S C 0 1 2
Calcanel reconstruction S C 0 1 2
Capsulorrhaphy S C 0 1 2
Carpal tunnel release S C 0 1 2
Closed reduction fracture S C 0 1 2
Hand surgery with implants S C 0 1 2
Harrington rod instrumentation
and/or Dwyer procedure S C 0 1 2
Heel cord lengthening S C 0 1 2
Laminectomy S C 0 1 2
Olecranon bursa, excision of S C 0 1 2
ORIF, internal fixation with
compression set S C 0 1 2
Patellectomy S C 0 1 2
PuttPlatt/Bankart
procedure/rotator cuff repair S C 0 1 2
Reduction with compression sets S C 0 1 2
Reimplanation of digits S C 0 1 2
Repair hammer toes S C 0 1 2
Sacro-iliac (SI) joint screws S C 0 1 2
Sharrad procedure S C 0 1 2
Spica cast, application S C 0 1 2
Spinal fusion S C 0 1 2
Tendon transplants (hand & foot) S C 0 1 2
ORTHOPEDICS - Arthroscopy
Ankle S C 0 1 2
Elbow S C 0 1 2
Knee S C 0 1 2
Shoulder S C 0 1 2
Hip compression nails & lag screws
Jewett S C 0 1 2
Kuntscher rod S C 0 1 2
Lottes S C 0 1 2
Rush S C 0 1 2
Schneider S C 0 1 2
Zimmer S C 0 1 2
Illiac crest bone graft S C 0 1 2
Insertion Austin Moore hip
prostheses S C 0 1 2
Intramedullary rods
Extraction S C 0 1 2
Femoral S C 0 1 2
Humeral S C 0 1 2
Insertion S C 0 1 2
Supracondylar S C 0 1 2
Tibal S C 0 1 2
Total joint replacement/revisions
Hip S C 0 1 2
Knee S C 0 1 2
Shoulder S C 0 1 2
PLASTICS
Abdominal lipectomy S C 0 1 2
Abdominalplasty S C 0 1 2
Blepharoplasty S C 0 1 2
Cleft lip repair S C 0 1 2
Dermabrasion S C 0 1 2
Face lift S C 0 1 2
Mentoplasty S C 0 1 2
Otoplasty S C 0 1 2
Pedicle grafts S C 0 1 2
Rhytidectomy S C 0 1 2
Scar revisions S C 0 1 2
Split thickness skin grafting S C 0 1 2
Tissue expanders S C 0 1 2
PLASTICS - Mammoplasty
Augmentation S C 0 1 2
Reduction S C 0 1 2
Tramflaps with reconstructive
mammoplasty S C 0 1 2
EAR, NOSE & THROAT
Adenoidectomy S C 0 1 2
Caldwwell-Luc S C 0 1 2
Cleft lip/palate repair S C 0 1 2
Closed reduction nasal fx S C 0 1 2
Ethmoidectomy S C 0 1 2
Excision of salivary gland tumor S C 0 1 2
Fenestration procedure S C 0 1 2
Frontal flap sinus procedure S C 0 1 2
Glossectomy S C 0 1 2
Laryngectomy S C 0 1 2
Mandibulectomy S C 0 1 2
Maxillary advancement with graft S C 0 1 2
Maxillectomy S C 0 1 2
Myringoplasty S C 0 1 2
Myringotomy with PE tube insertion S C 0 1 2
Nasal polypectomy S C 0 1 2
Open reduction facial fx S C 0 1 2
Parotidectomy S C 0 1 2
Pharyngeal flap procedure S C 0 1 2
Radical neck dissection S C 0 1 2
Ranulectomy S C 0 1 2
Rhinoplasty/septoplasty S C 0 1 2
Selective osteotomy of
maxilla/mandible S C 0 1 2
Sinus endoscopy S C 0 1 2
Sinusotomy S C 0 1 2
Stapedectomy S C 0 1 2
Submucous resection S C 0 1 2
Tonsillectomy S C 0 1 2
Tracheostomy S C 0 1 2
Tympanoplasty S C 0 1 2
ORAL
Closed reducation facial
fractures/wiring S C 0 1 2
Excision odontoma S C 0 1 2
Excision of deciduous teeth S C 0 1 2
Extraction of impacted molars S C 0 1 2
Fractured jaws, mandibular &
zagomatic S C 0 1 2
Ginivectomy S C 0 1 2
LeFort osteotomies S C 0 1 2
Maxillary procedure with graft S C 0 1 2
Pediatric dentistry S C 0 1 2
Sagittal osteotomy S C 0 1 2
Temporomandibular (TMJ)
with athroplasty S C 0 1 2
TMJ exploration S C 0 1 2
OPHTHALMOLOGY
Cataract extractuin with IOL S C 0 1 2
Corneal transplant S C 0 1 2
Dacryocystectomy S C 0 1 2
Eye enucleation S C 0 1 2
Excision of chalazion S C 0 1