This skills assessment is designed to determine your level of competency in the areas listed below. By completing this checklist to the best of your ability, you will help us match your skills and areas of interest with our available assignments. Please indicate your appropriate level for each category as well as the date last performed.

Traveler Name:
Traveler Email:
Recruiter Name:
Date:

COMPETENCY LEVELSDATE LAST PERFORMED
1 = Functionally IndependentWithin 6 Months
2 = Some Experience6 mo. - 12 mo. ago
3 = Minor or No ExperienceOver 1 year ago
 Not Performed / Never Worked

SkillsScrub / CirculateCompetency LevelDate Last Performed
GENERAL SURGERY
AdrenalectomyScrub
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AppendectomyScrub
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Bowel Repairs/ResectionsScrub
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CholecystectomyScrub
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ColectomyScrub
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Colonoscopy/SigmoidoscopyScrub
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Colostomy/IleostomyScrub
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Esophageal ResectionScrub
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EsophagoscopyScrub
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GastrectomyScrub
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Gastric Bypass/StaplingScrub
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GastroscopyScrub
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HemorrhoidectomyScrub
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Hepatic ResectionScrub
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Herniations (Hiatal, Diaphragm)Scrub
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Herniorrhaphy (Femoral/Inguinal)Scrub
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LaparascopyScrub
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LaparotomyScrub
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MasectomyScrub
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Minor Case setupScrub
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NephrectomyScrub
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Nissen FundoplicationScrub
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PancreatectomyScrub
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PilonidalcystectomyScrub
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Portal/Caval ShuntScrub
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Pyloric StenosisScrub
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Rectal CasesScrub
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SplenectomyScrub
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TransabdominalScrub
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Vagotomy/PyloraplastyScrub
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Whipple ProcedureScrub
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EAR, NOSE, THROAT
Acoustic NeuromaScrub
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Cleft Lip/Palate RepairScrub
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Endoscopic Sinus SurgeryScrub
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EthmoidectomyScrub
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Fenestration ProcedureScrub
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GlossectomyScrub
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LaryngectomyScrub
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LaryngoscopyScrub
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Mandibular FracturesScrub
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MastoidectomyScrub
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Maxillary FracturesScrub
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MyringoplastyScrub
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Myringotomy/PE TubesScrub
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Neck DissectionScrub
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Open Reduction Facial FracturesScrub
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Open Reduction Tripod FracturesScrub
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Orbital/Zygomatic FracturesScrub
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ParathyroidectomyScrub
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Reduction Nasal FractureScrub
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StapedectomyScrub
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T & AScrub
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ThyroidectomyScrub
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TracheostomyScrub
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TympanoplastyScrub
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Vocal Cord StrippingScrub
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TRAUMA
Blunt Traumatic InjuriesScrub
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BurnsScrub
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Multiple InjuriesScrub
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Penetrating Traumatic InjuriesScrub
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CARDIOVASCULAR
AngioplastyScrub
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Aortic AneurysmScrub
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Aortic Balloon InsertionScrub
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Aortic Valve ReplacementScrub
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Artial Septal Defect RepairScrub
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A-V Fistula/ShuntScrub
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Carotid EndarterectomyScrub
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Central Venous Access PlacementsScrub
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Coarctation of Aorta-ResectionScrub
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Coronary Artery Bypass GraftScrub
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Fem-Popliteal Bypass GraftScrub
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Mitral Valve ReplacementScrub
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Pacemaker ImplantationScrub
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Pacemaker InsertionScrub
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Patent Ductus ArteriosusScrub
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Pericardial ProceduresScrub
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Port-A-Cath InsertionScrub
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Tetralogy of FallotScrub
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Vein HarvestScrub
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Ventral Septal Defects-RepairScrub
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Ventricular AneurysmScrub
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OPTHAMOLOGY
CataractScrub
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Detached RetinaScrub
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IridotomyScrub
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LASIKScrub
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Lid and Muscle ProceduresScrub
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Orbit/Globe FracturesScrub
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Pterygium RepairScrub
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ORAL
Closed Reduction Facial Fxs/WiringScrub
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Excision OdontomaScrub
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Extraction of Deciduous TeethScrub
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Extraction of Impacted MolarsScrub
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Fractures Jaw, Mandible, ZygomaScrub
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LeFort OsteotomiesScrub
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Maxillary Procedure with GraftScrub
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TMJ with Exploration/ArthroplastyScrub
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ORTHOPEDIC
ACL RepairScrub
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Amputation Arm/LegScrub
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Arthroscopy-AnkleScrub
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Arthroscopy-ElbowScrub
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Arthroscopy-KneeScrub
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Arthroscopy-ShoulderScrub
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Cast ApplictionScrub
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Closed Fracture ReductionScrub
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External FixationsScrub
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Foot Procedure/FracturesScrub
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Hand Surgery/Fx RepairsScrub
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Harrington Rod Insertion-Scrub
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IM RodsScrub
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Nailing ProceduresScrub
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ORIF-Lower ExtremityScrub
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ORIF-Upper ExtremityScrub
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Spica Cast ApplicationScrub
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Spinal FusionScrub
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Total Hip ReplacementScrub
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Total Knee ReplacementScrub
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Total Shoulder ReplacementScrub
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UROLOGY
CircumcisionScrub
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CystoscopyScrub
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HydrocelectomyScrub
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Hypospadis RepairScrub
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Incontinence Device PlacementScrub
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LithotripsyScrub
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OrchiopexyScrub
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Penile ProthesisScrub
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ProstatectomyScrub
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Radical Node DessectionScrub
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TURPScrub
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VasectomyScrub
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OB/GYN
A & P RepairScrub
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Abdominal HysterectomyScrub
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ColposcopyScrub
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C-SectionScrub
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Dilation & CurettageScrub
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LaparoscopyScrub
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Marshall MarchettiScrub
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Marsupalization Bartholin CystScrub
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SalpingoplastyScrub
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Suction CurettageScrub
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Tubal LigationScrub
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Vaginal HysterectomyScrub
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VulvectomyScrub
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PLASTICS
AbdominalplastyScrub
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BlepharoplastyScrub
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DermabrasionScrub
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FaceliftsScrub
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Mammoplasty-AugmentationScrub
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Mammoplasty-ReductionScrub
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Muscle FlapsScrub
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OtoplastyScrub
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Pedicle GraftsScrub
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RhinoplastyScrub
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Scar RevisionsScrub
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SeptoplastyScrub
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Skin Grafts/Split ThicknessScrub
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Vein StrippingScrub
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TRANSPLANT
Bone-Harvest/TransplantScrub
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Eye-Harvest/TransplantScrub
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Heart-Harvest/TransplantScrub
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Liver-Harvest/TransplantScrub
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Lung-Harvest/TransplantScrub
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Pancreas-Harvest/TransplantScrub
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Renal-Harvest/TransplantScrub
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Skin-Harvest/TransplantScrub
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EQUIPMENT
Aquamatic K Thermia UnitScrub
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Argon Beam CoagulatorScrub
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Arthroscopy CamerasScrub
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Blood WarmerScrub
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Bovie Electrosurgical UnitScrub
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Cardiac Monitor-DefibrillatorScrub
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Cell SaverScrub
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CentrifugeScrub
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Cidex SterilizationScrub
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Cry-Ophthalmic UnitScrub
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DermatomeScrub
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DrillsScrub
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Dual Tract LightsScrub
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Ethylene Oxide SterilizerScrub
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Fiber Optic LumiatorScrub
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Flash AutoclaveScrub
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Fluid PumpsScrub
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Kiddie Pneumatic TourniquetScrub
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LasersScrub
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Nerve StimulatorScrub
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Operating MicroscopeScrub
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Pleur-e-vac UnitsScrub
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ShaversScrub
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Stapling InstrumentScrub
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Suction Unit DisposableScrub
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Ultrasonic Cleaner-AMSCOScrub
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Vac-pac PositionerScrub
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Washer Sterilizer-AMSCOScrub
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THORACIC
BronchoscopyScrub
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Chest TubesScrub
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Esophageal RepairScrub
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MediastinoscopyScrub
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Pneumonectomy/LobectomyScrub
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ThoacicAortic AnerrysmScrub
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ThoracoplastyScrub
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ThoracotomyScrub
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Tracheal ResectionScrub
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CRANIOTOMY
AneurysmScrub
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Cervical FusionScrub
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Cervical LaminectomyScrub
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CranioplastyScrub
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Crutchfield Tong InsertionScrub
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Halo Traction ApplicationScrub
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HypophysectomyScrub
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LaminectomyScrub
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Meningocele RepairScrub
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Shunt InsertionsScrub
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TraumaScrub
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TumorScrub
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Ventricular ProceduresScrub
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NEUROLOGY
Acoustic NeuromaScrub
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Anterior Cervical FusionScrub
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A-V MalformationScrub
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Burr HolesScrub
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Carotid LigationScrub
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Cervical SympathectomyScrub
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CraniotomyScrub
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DiscectomyScrub
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LaminectomyScrub
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Myelomeningocele RepairScrub
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Shunt ProcedureScrub
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Ulnar Nerve TransferScrub
Circulate
VentriculostomyScrub
Circulate
Please list any licenses or certifications held and when they expire:
Please list any area of competence (techniques, procedures, technologies, skills, etc.) where you would like to pursue additional training in order to enhance the level of care, treatment, or services to the population(s) that you serve:


Age Specific Competency

Please indicate the appropriate level for each category. When evaluating your competency level, please focus on the following guidelines: Ability to ensure a safe and caring environment for the specific age groups indicated below. Ability to communicate and instruct patients in the designated age groups. Ability to evaluate age-appropriate behavior and skills.

Age GroupCompetency LevelDate Last Performed
Newborn (birth-30 days)
Infant (30 days-1 yrs)
Toddler (1-3 yrs)
Preschooler (3-5 yrs)
School Age (5-12 yrs)
Adolescents (12-18 yrs)
Young Adults (18-39 yrs)
Middle Adults (39-64 yrs)
Older Adults (64 yrs +)

To the best of my knowledge, the information represented above is an accurate reflection of my skills and abilities, and I authorize Sunbelt Staffing to share the above skills checklist with its clients.