Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
GENERAL
Abdomen 0 1 2
Aorta 0 1 2
Biliary Tree 0 1 2
Breast 0 1 2
Doppler studies
Carotid 0 1 2
Venous (arm/leg) 0 1 2
Arterial (arm/leg) 0 1 2
Arterial graft duplex 0 1 2
Renal Doppler 0 1 2
Transcranial Doppler 0 1 2
Segmental pressures 0 1 2
Gall bladder 0 1 2
Heart 0 1 2
Liver 0 1 2
Transvaginal procedures 0 1 2
Obstetrical examinations 0 1 2
Neonatal abdomen 0 1 2
Neonatal head 0 1 2
Pancreas 0 1 2
Pelvis 0 1 2
Renal 0 1 2
Small Parts 0 1 2
Thyroid 0 1 2
Transrectal procedures 0 1 2
SPECIAL PROCEDURES
Biopsy procedures 0 1 2
Cyst aspiration 0 1 2
Paracentesis 0 1 2
Thoracentesis 0 1 2
Hysterosonography 0 1 2
Please list the type of work-related equipment or computers you have used:
Please list any additional skills or procedures you have performed:

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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