Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
Diagnostics
Performance of sleep study in sleep lab 0 1 2
Performance of portable sleep study at home 0 1 2
Performance of portable sleep study in hospital 0 1 2
Performance of EEG 0 1 2
Performance of ECG 0 1 2
ABG proficiency (respiratory care practitioners only) 0 1 2
Performance of Nocturnal Penile Tumescence 0 1 2
Performance of Multiple Sleep Latency Test (MSLT) 0 1 2
Performance of Maintenance of Wakefulness test 0 1 2
Procedures and Skills
International 10-20 system 0 1 2
Scoring: Staging sleep, PLM’s resp, ECG’s, Oxygen Sat. 0 1 2
Oximetry 0 1 2
Placement of body electrodes 0 1 2
Thoracic and abdominal belts 0 1 2
Transcutaneous monitoring 0 1 2
Nasal mask fitting 0 1 2
Nasal CPAP titration 0 1 2
Nasal Bilevel titration 0 1 2
Nasal ventilation (ventilator) 0 1 2
Oxygen set up (NC, mask, trach) 0 1 2
Oxygen Titration 0 1 2
ABG drawing (resp care pract only) 0 1 2
Arterial blood gas interpretation 0 1 2
Audio video monitoring 0 1 2
Sleep logs 0 1 2
Artifact recognition: ECG, 60 cycle, respiratory, pacemaker, sweat 0 1 2
Artifact trouble shooting 0 1 2
Nasotracheal suctioning (resp care) 0 1 2
Endotracheal suctioning (resp care) 0 1 2
Electroencephalogram rhythms 0 1 2
Electrocardiogram rhythms 0 1 2
Seizure recognition & precaution 0 1 2
Electrode impedances 0 1 2
REM behavioral disorder precaution 0 1 2
Cleaning and disinfection 0 1 2
Pt. Safety & Emergency procedures 0 1 2
Pt. Education & Instruction 0 1 2
Pediatric Polysomnography 0 1 2
Sleep walking precautions 0 1 2
Knowledge of Medication
Knowledge of barbiturates 0 1 2
Knowledge of anticonvulsants 0 1 2
Knowledge of narcotics 0 1 2
Knowledge of stimulants 0 1 2
Knowledge of anticoagulants 0 1 2
Knowledge of heart meds 0 1 2
Knowledge of Analgesics 0 1 2
Knowledge of benzodiazepines 0 1 2
Knowledge of antidepressants 0 1 2
Additional diagnostic procedures or skills Performed?
Equipment
CPAP 0 1 2
Respiraonics Maestro 0 1 2
Respironics Virtuoso 0 1 2
Respironics BiPAP S-D 0 1 2
Respironics BiPAP ST/D 0 1 2
Oximeters 0 1 2
Humidifiers 0 1 2
Nihon Kohden Analog Data Acquisition System 0 1 2
Nihon Kohden Digital Data Acquisition System 0 1 2
Sensor Medics Windows Based System 0 1 2
Senso Medic DOS Base System 0 1 2
Sandman 0 1 2
Sandman NT 0 1 2
Grass Analog System 0 1 2
Grass Digital System 0 1 2
Embla 0 1 2
RemBrandt 0 1 2
Digitrace 0 1 2
Nicolet 0 1 2
Alice 3 0 1 2
Alice 4 0 1 2
Biological DOS Based System 0 1 2
Biological Windows Based System 0 1 2
Medgraphics Lab 0 1 2
Medgraphics P Series 0 1 2
Puritan Bennett Knight Star 335 0 1 2
Puritan Bennett Knight Star 320 0 1 2
Puritan Bennett Knight Star 316 0 1 2
Healthdyne Tranquility 0 1 2
Healthdyne Quantum 0 1 2
Sullivan VPAP 0 1 2
Sullivan CPAP 0 1 2
Light Therapy 0 1 2
Additional types of equipment y used:
Work Settings:
Hospital labs / Centers No Yes
Independent Labs No Yes
Intensive Care Units No Yes
Patient Home No Yes
Nursing Home No Yes
Professional Titles:
Sleep Tech No Yes
RPSGT 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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