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Surgical Technician (ORT) Skills Checklist

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______________________________________________ XXX-XX-___________ _______________________

Print Name Last 4 of SS # Date Completed

Directions

Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional.

Experience

1 - No Experience (has never done or observed)

2 - Requires Training (In-Service) - not performed within last 36 months

3 - Limited Experience (requires assistance or training) - performed within the last 24 months 4 - Experienced (routinely performs without assistance) - performed within the last 12 months 5 - Able to Supervise, Precept and Teach - performed within the last 6 months

EQUIPMENT: Experience NITROGEN TANK 1 2 3 4 5 CUSA 1 2 3 4 5 LASER EQUIPMENT 1 2 3 4 5 CELL SAVER 1 2 3 4 5 AUTOTRANSFUSION DRAINING 1 2 3 4 5 AUTOCLAVE 1 2 3 4 5 CRYO-OPTHALMIC UNIT 1 2 3 4 5 STERIS UNIT 1 2 3 4 5 VIDEO SYSTEMS/CAMERA 1 2 3 4 5 PNEUMATIC TOURNIQUET 1 2 3 4 5 ELECTROSURGICAL UNIT 1 2 3 4 5 VENODYNE 1 2 3 4 5 DERMATONE/MESH GRAFT 1 2 3 4 5 FIBEROPTIC EQUIPMENT 1 2 3 4 5 CIDEX SOAK 1 2 3 4 5 PULSEVAC IRRIGATION 1 2 3 4 5 MICROSCOPES 1 2 3 4 5

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EQUIPMENT: Experience

SAW / DRILLS 1 2 3 4 5

FRACTURE TABLES 1 2 3 4 5

FIBER OPTIC LAMINATOR 1 2 3 4 5

STAPLING DEVICES 1 2 3 4 5

CAVITRON 1 2 3 4 5

CARDIOVASCULAR Experience

RIB RESECTION 1 2 3 4 5

INTRA-AORTIC BALLOON PUMP 1 2 3 4 5

AORTIC ANEURYSM 1 2 3 4 5

AORTIC FEMORAL BYPASS GRAFT 1 2 3 4 5

LOBECTOMY 1 2 3 4 5

PACEMAKERS 1 2 3 4 5

THORACOTOMY 1 2 3 4 5

FEMORAL/POPLITEAL BYPASS 1 2 3 4 5

ENDOSCOPIC VEIN HARVESTING 1 2 3 4 5

ASV/VSD/SEPTAL DEFECTS 1 2 3 4 5

OFF PUMP BYPASS 1 2 3 4 5

CARDIAC CATH LAB 1 2 3 4 5

VALVE REPLACEMENT 1 2 3 4 5

CORONARY ARTERY BYPASS 1 2 3 4 5

GENERAL SURGERY Experience

SPLENECTOMY 1 2 3 4 5 BOWEL RESECTION 1 2 3 4 5 VAGOTOMY 1 2 3 4 5 ILEOSTOMY 1 2 3 4 5 ORGAN PROCUREMENT 1 2 3 4 5 TRACHEOTOMY 1 2 3 4 5

ABDOMINAL PERINEAL RESECT. 1 2 3 4 5

HERNIORRHAPHY 1 2 3 4 5

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GENERAL SURGERY Experience

COLOSTOMY 1 2 3 4 5

SAPHENOUS VEIN LIGATION 1 2 3 4 5

ADRENALECTOMY 1 2 3 4 5 MASTECTOMY 1 2 3 4 5 CHOLANGIOGRAM 1 2 3 4 5 PANCREATECTOMY 1 2 3 4 5 HIATAL HERNIORRHAPHY 1 2 3 4 5 GASTRECTOMY 1 2 3 4 5 NEUROLOGY Experience

SHUNT PROCEDURES VP/VA/LP 1 2 3 4 5

BURR HOLES 1 2 3 4 5 MYLELOMENINGOCELE REPAIR 1 2 3 4 5 CAROTID LIGATION 1 2 3 4 5 SPINAL FUSIONS 1 2 3 4 5 CERVICAL SYMPHATHECTOMY 1 2 3 4 5 VENTRICULOSTOMY 1 2 3 4 5

INSERTION OF NERVE STIMULUS 1 2 3 4 5

LAPAROSCOPIC PROCEDURES 1 2 3 4 5 HALO TRACTION 1 2 3 4 5 SUBDURAL HEMATOMA 1 2 3 4 5 LAMINECTOMY 1 2 3 4 5 CRANIOPLASTY 1 2 3 4 5 DISECTOMY 1 2 3 4 5 CRANIOTOMY 1 2 3 4 5 ENDOSCOPY Experience LARYNGOSCOPY 1 2 3 4 5 CULDOSCOPY 1 2 3 4 5 TUBAL LIGATION 1 2 3 4 5 APPENDECTOMY 1 2 3 4 5 THORACOSCOPY 1 2 3 4 5

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ENDOSCOPY Experience HYSTEROSCOPY 1 2 3 4 5 PELVISCOPY 1 2 3 4 5 COLONOSCOPY 1 2 3 4 5 VAGINAL HYSTERECTOMY 1 2 3 4 5 GASTROSCOPY 1 2 3 4 5 MEDIASTINOSCOPY 1 2 3 4 5 BRONCHOSCOPY 1 2 3 4 5 SALPINGO-OOPHORECTOMY 1 2 3 4 5 CYCTOSCOPY 1 2 3 4 5 SIGMOIDOSCOPY 1 2 3 4 5 ESOPHAGOSCOPY 1 2 3 4 5 HERNIA REPAIR 1 2 3 4 5 CHOLECYSTECTOMY 1 2 3 4 5 COLON RESECTION 1 2 3 4 5

EAR, NOSE & THROAT Experience

SEPTOPLASTY 1 2 3 4 5 ADENOIDECTOMY 1 2 3 4 5 THRACHEOSTOMY 1 2 3 4 5 RADICAL NECK 1 2 3 4 5 MASTOIDECTOMY 1 2 3 4 5 CALDWELL-LUC 1 2 3 4 5 SINUSOTOMY 1 2 3 4 5 TONSILLECTOMY 1 2 3 4 5 CLEFT LIP 1 2 3 4 5 MANDIBULECTOMY 1 2 3 4 5 LARYNEGECTOMY 1 2 3 4 5 GYNECOLOGY Experience TUBAL LIGATION 1 2 3 4 5 ABDOMINAL HYSTERECTOMY 1 2 3 4 5 RADIUM INSERTION 1 2 3 4 5

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GYNECOLOGY Experience DILATION/CURETTAGE 1 2 3 4 5 VAGINECTOMY 1 2 3 4 5 SHIRODKAR PROCEDURE 1 2 3 4 5 C-SECTION 1 2 3 4 5 LASER SURGERY 1 2 3 4 5 TOP 1 2 3 4 5 VAGINAL HYSTERECTOMY 1 2 3 4 5 HYSTERECTOMY - ABDOMINAL 1 2 3 4 5 HYSTERECTOMY - VAGINAL 1 2 3 4 5 OPTHAMOLOGY Experience RETINAL DETACHMENT 1 2 3 4 5 CORNEAL TRANSPLANT 1 2 3 4 5 CATARACT EXTRACTION 1 2 3 4 5 ENUCLEATION 1 2 3 4 5 SCLERAL BUCKLE 1 2 3 4 5 IOL IMPLANTS 1 2 3 4 5 ORBITAL IMPLANTS 1 2 3 4 5 ORBITAL FRACTURES 1 2 3 4 5 ORTHOPEDIC Experience DISLOCATION REPAIRS 1 2 3 4 5 ARTHOTOMY 1 2 3 4 5

TOTAL JOINT REPLACEMENTS 1 2 3 4 5

ACHILLES TENDON REPAIR 1 2 3 4 5

PATELLECTOMY 1 2 3 4 5 EXTERNAL COMPRESSIONS 1 2 3 4 5 ORIF 1 2 3 4 5 AMPUTATION 1 2 3 4 5 SPICA CAST 1 2 3 4 5 REDUCTION OF EXTREMITIES 1 2 3 4 5 TENDON IMPLANTS 1 2 3 4 5

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ORTHOPEDIC Experience

ARTHROSCOPY 1 2 3 4 5

HIP COMPRESSION NAILS 1 2 3 4 5

TRANSPLANTS Experience MULTI ORGANS 1 2 3 4 5 BONE MARROW 1 2 3 4 5 HEART/LUNG 1 2 3 4 5 SKIN 1 2 3 4 5 CORNEAL 1 2 3 4 5 LIVER 1 2 3 4 5 PANCREAS 1 2 3 4 5 KIDNEY 1 2 3 4 5 BONE 1 2 3 4 5 HARVESTING 1 2 3 4 5 UROLOGY Experience HYPOSPADIUS REPAIR 1 2 3 4 5 LITHOTRIPSY 1 2 3 4 5 PROSTATACTOMY 1 2 3 4 5 URETEROSCOPY 1 2 3 4 5 URETEROLITHOMY 1 2 3 4 5 CIRCUMCISION 1 2 3 4 5 ORCHIECTOMY 1 2 3 4 5 VASECTOMY 1 2 3 4 5 CYSTOSCOPY 1 2 3 4 5 NEPHRECTOMY 1 2 3 4 5 IMPLANTS 1 2 3 4 5 CYSTECTOMY 1 2 3 4 5 VASCULAR Experience EMBOLECTOMY 1 2 3 4 5 AORTIC ANEURYSM 1 2 3 4 5 THROMBECTOMY 1 2 3 4 5

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VASCULAR Experience

ANGIOGRAPHY 1 2 3 4 5

AORTIC ENDARTERECTOMY 1 2 3 4 5

PERIPHERAL VASCULAR BYPASS 1 2 3 4 5

VENA CAVA LIGATION 1 2 3 4 5

CAROTID ANEURYSM/GRAFT 1 2 3 4 5 PLASTICS Experience OTOPLASTY 1 2 3 4 5 FACE LIFT 1 2 3 4 5 REDUCTION 1 2 3 4 5 ADBOMINAL LIPECTOMY 1 2 3 4 5 SKIN GRAFTING 1 2 3 4 5 BREAST AUGMENTATION 1 2 3 4 5 SCAR REVISIONS 1 2 3 4 5 BLEPHAROPLASTY 1 2 3 4 5 LIPOSUCTION 1 2 3 4 5 MAMMOPLASTY 1 2 3 4 5 RECONSTRUCTION 1 2 3 4 5 TRAUMA Experience MVA'S 1 2 3 4 5 BURNS 1 2 3 4 5 STAB WOUNDS 1 2 3 4 5 TRAUMATIC AMPUTATIONS 1 2 3 4 5 GUNSHOT WOUNDS 1 2 3 4 5 JUMPERS 1 2 3 4 5 DRUG OVERDOSE 1 2 3 4 5 LEVEL 1 TRAUMA 1 2 3 4 5 IN PATIENT HOSPITAL 1 2 3 4 5

OUT PATIENT SETTING 1 2 3 4 5

AGE APPROPRIATE CARE Experience

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The information represented above is true and correct to the best of my knowledge. I also authorize

Specialty Professional Services, Corp to share the above skills checklist with its facility clients.

AGE APPROPRIATE CARE Experience

INFANT (30 DAYS - 1 YEAR) 1 2 3 4 5

TODDLER (1 - 3 YEARS) 1 2 3 4 5

PRESCHOOLER (3 - 5 YEARS) 1 2 3 4 5

SCHOOL AGE (5 - 12 YEARS) 1 2 3 4 5

ADOLESCENTS (12 - 18 YEARS) 1 2 3 4 5

YOUNG ADULTS (18 - 39 YEARS) 1 2 3 4 5

MIDDLE ADULTS (39 - 64 YEARS) 1 2 3 4 5

OLDER ADULTS (64+ YEARS) 1 2 3 4 5

References

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