Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
GENERAL DIAGNOSTIC
Abdominal-Perineal Resection 0 1 2
Adrenalectomy 0 1 2
Appendectomy 0 1 2
Cholecystectomy/Cholangiogram 0 1 2
Colectomy 0 1 2
Colon Resection 0 1 2
Colostomy/Ileostomy 0 1 2
Endoscopic Procedures 0 1 2
Gastrectomy 0 1 2
Hepatic Resection 0 1 2
Hernia Repair 0 1 2
Hydrocelectomy 0 1 2
Leveen-Peritoneal Shunt 0 1 2
Lumbar Sympathectomy 0 1 2
Minor Case Set-Up (Breast, Biopsies, Hernias) 0 1 2
Nissen Fundoplication 0 1 2
Pancreatectomy/Pacreatogram 0 1 2
Pilonidal Cystectomy 0 1 2
Portal Caval Shunt 0 1 2
Radical Mastectomy 0 1 2
Rectal Cases 0 1 2
Saphenous Vein Ligation and Stripping 0 1 2
Splenectomy 0 1 2
Staging Laporotomy 0 1 2
Thyroglossal Duct Cyst Excision 0 1 2
Thyroidectomy 0 1 2
Vagotomy 0 1 2
Whipple Procedure 0 1 2
VASCULAR
A-V Fistula Shunt 0 1 2
Aortic Aneurysm 0 1 2
Aorto-Illiac/Femoral Graft 0 1 2
Brachio Axillary Dacron Fistula 0 1 2
Carotid Endarterectomy 0 1 2
Femoral-Popliteal Graft 0 1 2
Leaking Ruptured Aneurysm 0 1 2
Mohin-Uddin Umbrella
Resection Carotid Aneurysm with Graft 0 1 2
Tenckhoff Catheter Placement 0 1 2
Thrombectomy 0 1 2
Vena Cava Ligation 0 1 2
THORACIC / OPEN HEART
Cervical Rib Excision 0 1 2
Chamberlain Procedure 0 1 2
Closed Thoracotomy 0 1 2
Esophagectomy 0 1 2
Heller Procedure 0 1 2
CABG 0 1 2
Mitral or Aortic Valve Replacement 0 1 2
Patent Ductus Arteriosus 0 1 2
Tetrology of Fallot 0 1 2
VSD (Ventral or Ventricular Septal Defect) 0 1 2
ASD (Atrial Septal Defect) 0 1 2
Pacemaker Implantation Endocardial 0 1 2
Pacemaker Implantation Myocardial 0 1 2
Pneumonectomy/Lobectomy 0 1 2
Port-A-Cath Insertion 0 1 2
Resection Coarctation Aorta 0 1 2
First Rib Resection 0 1 2
Thoracoplasty 0 1 2
Tracheal Resection 0 1 2
Transthoracic Diaphragmatic Hemorrhaphy 0 1 2
Transplant Experience 0 1 2
NEUROLOGY
Burr Holes (Subdural Hematoma) 0 1 2
Cartoid Endarterectomy 0 1 2
Cartoid Ligation 0 1 2
Cervical Laminectomy 0 1 2
Cervical Sympathectomy 0 1 2
Clipping of Intracranial Aneurysm 0 1 2
Craniectomy for Decompression Fracture 0 1 2
Cranioplasty 0 1 2
Craniotomy for Tumor Excision 0 1 2
Crutchfield Tong Insertion 0 1 2
Exterior Cervical Fusion 0 1 2
Hypophysectomy 0 1 2
Laminectomy 0 1 2
Lumbar Laminectomy 0 1 2
Meningocele Repair 0 1 2
Transphenoid Hypothypectomy 0 1 2
Ulna Nerve Transplant 0 1 2
VA & VP Shunt 0 1 2
Ventricular Procedures 0 1 2
Vinke Tong Insertion 0 1 2
ORTHOPEDICS
Achilles Tendon Repair 0 1 2
Amputation/Leg, Arm 0 1 2
Anterior Cruciate Ligament Repair 0 1 2
Application Halo Traction 0 1 2
Arthroscopic Surgery 0 1 2
Capsularrhaphy 0 1 2
Closed Reduction Fracture 0 1 2
Cup Arthroplasty/Insertion Prosthesis 0 1 2
Dwyer Anterior Fusion 0 1 2
Fracture Table Use 0 1 2
Hand Surgery with Implants 0 1 2
Harrington Rod Insertion 0 1 2
Heel Cord Lengthening 0 1 2
IM Rodding 0 1 2
Insertion Tibial Plateau Prosthesis 0 1 2
Nailing Procedures 0 1 2
Excision of Olecranon Bursa 0 1 2
Open Reduction Fracture 0 1 2
Patellectomy 0 1 2
Putti Platt/Bankart Procedure 0 1 2
Reduction with Compression Sets 0 1 2
Sharrard Procedure 0 1 2
Application of Spica Cast 0 1 2
Spinal Fusion 0 1 2
Insertion of Swanson Finger Prosthesis 0 1 2
Tendon Implants 0 1 2
Total Joint Replacements 0 1 2
Zimmer Hip Compression 0 1 2
GYNECOLOGY
Abdmonial Hysterectomy 0 1 2
C-Sections 0 1 2
Colpotomy 0 1 2
Dilation and Currettage 0 1 2
Laporoscopy 0 1 2
Marshall Marchetti 0 1 2
Marupialization Bartholin Cyst 0 1 2
Pelvic : Anterior 0 1 2
Pelvic : Posterior 0 1 2
Pelvic : Total 0 1 2
Radical Hysterectomy 0 1 2
Radium Insertion 0 1 2
GYNECOLOGY (CONT)
Salpingoplasty 0 1 2
Shirodkar Operation 0 1 2
Suction Curettage 0 1 2
Tubal Ligation 0 1 2
Tuboplasty/Microscope 0 1 2
Vaginal Hysterectomy 0 1 2
Vaginal Reconstruction 0 1 2
Vaginectomy 0 1 2
OPTHAMLOGY
Cataract Extraction 0 1 2
Corneal Transplant 0 1 2
Dacryocystectomy 0 1 2
Diathermy Operation 0 1 2
Enucleation 0 1 2
Iridectomy 0 1 2
Lid and Muscle Procedures 0 1 2
Orbital Implant 0 1 2
Phaco Emulsification 0 1 2
Pterygium Repair 0 1 2
Recession Resection 0 1 2
Repair Orbital Blowout Fracture 0 1 2
Retina 0 1 2
UROLOGY
Circumcision 0 1 2
Cystectomy 0 1 2
Hypospadius Repair 0 1 2
Nephrectomy 0 1 2
Orchiopexy 0 1 2
Perineal Prostatectomy 0 1 2
Suprapubic Prostatectomy 0 1 2
Pyelolithotomy 0 1 2
Pyeloplasty 0 1 2
Radical Node Dissection 0 1 2
Scott Incontinence Device 0 1 2
Scott Penile Prosthesis 0 1 2
TURP 0 1 2
Ureterolithotomy 0 1 2
Vasectomy 0 1 2
Vasovasostomy 0 1 2
PEDIATRICS
Bronchoscopy 0 1 2
Inguinal Hernia 0 1 2
Lap 0 1 2
Pyloric Stenosis 0 1 2
Cleft Lip/Palate Repair 0 1 2
PLASTICS
Abdominal Lipectomy 0 1 2
Augmentation MamMoplasty 0 1 2
Blepheroplasty 0 1 2
Dermabrasion 0 1 2
Mentoplasty 0 1 2
Myelomeningocele Repair 0 1 2
Otoplasty 0 1 2
Pedicle Grafts 0 1 2
Reduction MamMoplasty 0 1 2
Rhinoplasty 0 1 2
Scar Revisions 0 1 2
Skin Grafts/Split Thickness 0 1 2
EAR, NOSE & THROAT
Acoustic Neuroma 0 1 2
Caldwell-Luc 0 1 2
Closed Reduction Nasal Fracture 0 1 2
Mastoidectomy 0 1 2
Myringotomy 0 1 2
Stapendectomy 0 1 2
Tympanoplasty 0 1 2
Ethmoidectomy 0 1 2
Excision Salivary Gland Tumor 0 1 2
Fenestration Procedure 0 1 2
Frontal Flap Sinus Procedure 0 1 2
Glossectomy 0 1 2
Laryngectomy 0 1 2
Maxillary Advancement with Hip Graft 0 1 2
Nasal Polypectomy 0 1 2
Open Reduction Facial Fractures 0 1 2
Open Reduction Tripod Fractures 0 1 2
Parotidectomy 0 1 2
PE Tube Insertion 0 1 2
Pharyngeal Flap Procedure 0 1 2
Radical Neck Dissection 0 1 2
EAR, NOSE & THROAT (CONT)
Ranulectomy 0 1 2
Selective Osteotomy of Maxilla/Mandible 0 1 2
Sinusotomy 0 1 2
Submuccous Resection 0 1 2
Tonsillectomy 0 1 2
Tracheostomy 0 1 2
Vocal Cord Stripping 0 1 2
EQUIPMENT
Aquamatic K Thermia Unit 0 1 2
Arthroscopy Camera 0 1 2
Asteris 0 1 2
Blood Warmer 0 1 2
Bovie Electorsurgical Unit 0 1 2
Cardiac Monitor & Pacemaker: Electrodyn 0 1 2
Cavitran-Coopervision 0 1 2
Cell Saver 0 1 2
Set Synthes Compression 0 1 2
Cry-Opthalmic Unit 0 1 2
Dermatomes 0 1 2
Disposable Bovie Plates 0 1 2
Drills 0 1 2
Emerson Thoracic Pump 0 1 2
Eye Magnet 0 1 2
Ethylene Oxide Sterilizer 0 1 2
Flash Autoclave 0 1 2
Fiber Optic Luminators 0 1 2
Fluid Pumps 0 1 2
Kiddie Pneumatic Tourniquet 0 1 2
Kreiselman Resuscitator 0 1 2
Laser 0 1 2
Nerve Stimulator 0 1 2
Nitrous Oxide Bank 0 1 2
Operating Microscope 0 1 2
Suction Units 0 1 2
Steri-Vac Aeration Cabinet 0 1 2
Ultrasonic Cleaner-AMSCO 0 1 2
Vac-Pac Postioner 0 1 2
Vacuum Curettage 0 1 2
Washer Sterilizer-AMSCO 0 1 2
TRAUMA
Burns 0 1 2
Gunshot Wounds:
Chest 0 1 2
Abdomen 0 1 2
Motor Vehicle Accidents (Multiple Injuries) 0 1 2
Traumatic Amputations 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=Adult (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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