Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
CLINICAL SETTINGS
Hospital 0 1 2
Retail 0 1 2
Home Health 0 1 2
Long Term Care 0 1 2
Geriatrics 0 1 2
Mail Order 0 1 2
Clinic 0 1 2
Ambulatory Care 0 1 2
JOB EXPERIENCE
Admixture 0 1 2
Amutamixers 0 1 2
Chemo Therapy 0 1 2
Consulting (Facility) 0 1 2
Consulting (Patient long term care) 0 1 2
Delivery/Runner 0 1 2
Enteral Feeding 0 1 2
Infusion Pumps 0 1 2
Kinetic Dosing 0 1 2
Nutrition Protocols 0 1 2
PCA 0 1 2
Pyxis 10 minicell 0 1 2
TPN’s 0 1 2
Unit Dose 0 1 2
Nuclear Pharmacy 0 1 2
IV Preparation 0 1 2
Hyper Alimental 0 1 2
DIspensing 0 1 2
Compounding 0 1 2
Cart Fill 0 1 2
COMPUTER SKILLS
HBOC 0 1 2
Meditech 0 1 2
McKesson 3 pm 0 1 2
Mega Source 0 1 2
NDC 0 1 2
PDX 0 1 2
PPC (Pacific) 0 1 2
QS1 0 1 2
RX2000 0 1 2
Pharmak on 2000 0 1 2
RX Express 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 terminology of 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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