the selection process of the healthcare professional.
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Print Name
Last 4 Digits of SS#
Date
3 Intermittent Experience (May Require Assistance) 4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)
Areas Worked
Experience
Emergency 0 1 2 3 4 5 Urgent Care 0 1 2 3 4 5 Private Practice 0 1 2 3 4 5 HMO 0 1 2 3 4 5 MD Office 0 1 2 3 4 5 Schools 0 1 2 3 4 5 Health Department 0 1 2 3 4 5 Ambulatory Clinic 0 1 2 3 4 5
Rural Health Clinic 0 1 2 3 4 5
Psychiatric Facility 0 1 2 3 4 5
Correctional Facility 0 1 2 3 4 5
Mobile Medical Unit 0 1 2 3 4 5
Corporate Worksite 0 1 2 3 4 5
Occupational Health 0 1 2 3 4 5
Rehabilitation 0 1 2 3 4 5
Nursing Home/ Long-term Care Facility 0 1 2 3 4 5
Women's Health Clinic 0 1 2 3 4 5
Government Health Agency 0 1 2 3 4 5
Hospice/Palliative Care 0 1 2 3 4 5
Experience With
Experience
Diabetes 0 1 2 3 4 5
Contractures 0 1 2 3 4 5
Bedridden residents 0 1 2 3 4 5
Splinting of extremities 0 1 2 3 4 5
Local infiltration 0 1 2 3 4 5
Comprehensive physical assessment 0 1 2 3 4 5
Acute disease condition 0 1 2 3 4 5
Differential diagnosis 0 1 2 3 4 5
Order, may perform, & interpret screening & diagnostic test 0 1 2 3 4 5
Cardiovascular System
Experience
Congestive heart failure 0 1 2 3 4 5
Chronic obstructive pulmonary disease 0 1 2 3 4 5 Stasis ulcer of lower extremities 0 1 2 3 4 5
Angina 0 1 2 3 4 5
Pericarditis 0 1 2 3 4 5
Coronary artery disease 0 1 2 3 4 5
Functional murmurs 0 1 2 3 4 5
Congenital heart disease 0 1 2 3 4 5
Hypertension 0 1 2 3 4 5
Disorders – Emergencies
Experience
Anaphylaxis 0 1 2 3 4 5
Cardiac arrest 0 1 2 3 4 5
Seizures 0 1 2 3 4 5
Minor head injuries 0 1 2 3 4 5
Animal bites 0 1 2 3 4 5
Ingestions and poisonings 0 1 2 3 4 5
Overdose of sedative, hypnotics, opiates 0 1 2 3 4 5
Snake bites 0 1 2 3 4 5 Minor burns 0 1 2 3 4 5 Shock 0 1 2 3 4 5 Open wounds 0 1 2 3 4 5
Respiratory
Experience
Croup 0 1 2 3 4 5 Influenza 0 1 2 3 4 5 Tracheobronchitis 0 1 2 3 4 5 Bronchitis 0 1 2 3 4 5COPD (chronic obstructive pulmonary disease) 0 1 2 3 4 5
Asthma 0 1 2 3 4 5
URI (upper respiratory infection) 0 1 2 3 4 5
Obstructive Sleep Apnea 0 1 2 3 4 5
Pneumonia: Viral 0 1 2 3 4 5 Bacterial 0 1 2 3 4 5 Sinusitis: Bacterial 0 1 2 3 4 5 Nonbacterial 0 1 2 3 4 5
OB/GYN
Experience
Candida vaginitis 0 1 2 3 4 5
Dysmenorrhea 0 1 2 3 4 5
Abnormal pap smear findings 0 1 2 3 4 5
Pap smears 0 1 2 3 4 5
Trichomonal vaginitis 0 1 2 3 4 5
Atrophic vaginitis 0 1 2 3 4 5
Fibrocystic breast disease 0 1 2 3 4 5
Menopause 0 1 2 3 4 5
Intrapartum medications 0 1 2 3 4 5
Bartholin's cyst/abscess 0 1 2 3 4 5
Preparation for childbirth 0 1 2 3 4 5
Pregnancy - diagnosis and referral 0 1 2 3 4 5 Pain relief in active phase of labor 0 1 2 3 4 5
Medications in the third stage 0 1 2 3 4 5
Dysfunctional uterine bleeding 0 1 2 3 4 5
Medications in the postpartum phase 0 1 2 3 4 5
Rh blood factor 0 1 2 3 4 5
Mastitis 0 1 2 3 4 5
Birth control methods 0 1 2 3 4 5
Prenatal care 0 1 2 3 4 5
Fetal well-being 0 1 2 3 4 5
Nausea and vomiting with pregnancy 0 1 2 3 4 5
GI System
Experience
Constipation 0 1 2 3 4 5 Diarrhea (simple) 0 1 2 3 4 5 Acute gastroenteritis 0 1 2 3 4 5 Cholecystitis 0 1 2 3 4 5 Pyloric stenosis 0 1 2 3 4 5 Colic 0 1 2 3 4 5 Appendicitis 0 1 2 3 4 5Skin
Experience
Warts 0 1 2 3 4 5Basal cell carcinoma 0 1 2 3 4 5
Scabies 0 1 2 3 4 5
Skin - cont.
Experience
Diaper dermatitis 0 1 2 3 4 5 Acne 0 1 2 3 4 5 Folliculitis 0 1 2 3 4 5 Furuncles 0 1 2 3 4 5 Carbuncles 0 1 2 3 4 5 Herpes simplex 0 1 2 3 4 5 Herpes zoster 0 1 2 3 4 5 Malignant melanoma 0 1 2 3 4 5 Pityriasis Rosea 0 1 2 3 4 5 Contact dermatitis 0 1 2 3 4 5 Tinea corporis 0 1 2 3 4 5 Tinea pedis 0 1 2 3 4 5Ears, Nose and Throat
Experience
Epistaxis 0 1 2 3 4 5
Otitis externa 0 1 2 3 4 5
Serous otitis media 0 1 2 3 4 5
Acute purulent otitis media 0 1 2 3 4 5
Allergic rhinitis 0 1 2 3 4 5 Pharyngitis 0 1 2 3 4 5 Oral candidiasis 0 1 2 3 4 5
Eye
Experience
Conjunctivitis 0 1 2 3 4 5 Strabismus 0 1 2 3 4 5 Chalazion 0 1 2 3 4 5 Stye 0 1 2 3 4 5Musculoskeletal
Experience
Osteoporosis 0 1 2 3 4 5 Osteomyelitis 0 1 2 3 4 5 Rheumatoid arthritis 0 1 2 3 4 5 Juvenile diabetes 0 1 2 3 4 5 Gout 0 1 2 3 4 5Minor sprains and strains 0 1 2 3 4 5
Osteoarthritis 0 1 2 3 4 5
Musculoskeletal - cont.
Experience
Scoliosis 0 1 2 3 4 5
Tendonitis 0 1 2 3 4 5
Bursitis 0 1 2 3 4 5
Muscular dystrophy 0 1 2 3 4 5
Parasitic Infections
Experience
Pinworms 0 1 2 3 4 5
Ascariasis 0 1 2 3 4 5
Pediculosis 0 1 2 3 4 5
Genitourinary System
Experience
Syphilis 0 1 2 3 4 5
Chlamydia 0 1 2 3 4 5
Herpes 0 1 2 3 4 5
Cystitis 0 1 2 3 4 5
Pyelonephritis 0 1 2 3 4 5
Urinary tract infection 0 1 2 3 4 5
Benign prostatic hypertrophy 0 1 2 3 4 5
Vulvovaginitis 0 1 2 3 4 5
Hypospadias 0 1 2 3 4 5
Hydrocele 0 1 2 3 4 5
Gonococcal infections 0 1 2 3 4 5
Prostatitis 0 1 2 3 4 5
Nervous System
Experience
Vasovagal syncope 0 1 2 3 4 5 Migraine headaches 0 1 2 3 4 5 Multiple sclerosis 0 1 2 3 4 5 Headaches 0 1 2 3 4 5 Head injury 0 1 2 3 4 5 Tension 0 1 2 3 4 5 Anxiety 0 1 2 3 4 5 Parkinson’s 0 1 2 3 4 5 Alzheimer's 0 1 2 3 4 5 Bell’s Palsy 0 1 2 3 4 5
TIA (transient ischemic attacks) 0 1 2 3 4 5
Endocrine
Experience
Type I diabetes mellitus 0 1 2 3 4 5
Type II diabetes mellitus 0 1 2 3 4 5
Graves disease 0 1 2 3 4 5 Addison's disease 0 1 2 3 4 5 Juvenile diabetes 0 1 2 3 4 5 Hypoglycemia 0 1 2 3 4 5 Hypothyroidism 0 1 2 3 4 5
Hematological
Experience
Folic acid deficiency anemia 0 1 2 3 4 5
Aplastic anemia 0 1 2 3 4 5
Iron deficiency 0 1 2 3 4 5
Sickle cell anemia 0 1 2 3 4 5
Pernicious anemia 0 1 2 3 4 5
Psychosocial
Experience
Depression 0 1 2 3 4 5 Suicide 0 1 2 3 4 5 Obesity 0 1 2 3 4 5 Grief 0 1 2 3 4 5 Anxiety 0 1 2 3 4 5 Anorexia 0 1 2 3 4 5 Bulimia 0 1 2 3 4 5Collaboration
Experience
Family, support system, community resources 0 1 2 3 4 5
Consulting with Physicians 0 1 2 3 4 5
Consulting with Pharmacists 0 1 2 3 4 5
Consulting with Speech Therapist 0 1 2 3 4 5
Consulting with Dietician and Diet Aide 0 1 2 3 4 5 Consulting with Occupational Therapist 0 1 2 3 4 5
Referral to Pastoral Services 0 1 2 3 4 5
Drug Therapy
Experience
Prescription 0 1 2 3 4 5
Over the counter (OTC) 0 1 2 3 4 5
Drug Therapy - cont.
Experience
Knowledge of pharmacology 0 1 2 3 4 5
Knowledge of pharmacokinetics 0 1 2 3 4 5
Knowledge of drug interactions 0 1 2 3 4 5
Knowledge of side effects 0 1 2 3 4 5
Knowledge of potential adverse reactions:
Allergic reactions 0 1 2 3 4 5
Anaphylaxis reaction 0 1 2 3 4 5
TPN/Lipid Management 0 1 2 3 4 5
Management/Titration of IV Therapies 0 1 2 3 4 5 IV/PO Antibiotic Therapy and understanding of cultures 0 1 2 3 4 5
Dispensing Medication
Experience
Monitoring drug therapy 0 1 2 3 4 5
Management of controlled substances 0 1 2 3 4 5
Injections 0 1 2 3 4 5
Non-Pharmacologic Interventions
Experience
Medical nutrition therapy 0 1 2 3 4 5
Exercise 0 1 2 3 4 5
Cessation of substance abuse (alcohol, tobacco) 0 1 2 3 4 5 Mental health issues (stress management, depression) 0 1 2 3 4 5
Obesity management 0 1 2 3 4 5
Tube Feeding Management 0 1 2 3 4 5
Miscellaneous
Experience
Public health and health promotion 0 1 2 3 4 5
Research 0 1 2 3 4 5
Quality assurance 0 1 2 3 4 5
Leadership and teaching skills 0 1 2 3 4 5
Legal and ethical issues 0 1 2 3 4 5
Confidentiality 0 1 2 3 4 5
Cultural awareness 0 1 2 3 4 5
Self evaluation to improve patient care 0 1 2 3 4 5
Continuing education 0 1 2 3 4 5
Miscellaneous - cont.
Experience
Discharge planning / collaboration 0 1 2 3 4 5Suturing 0 1 2 3 4 5
Cell biopsy 0 1 2 3 4 5
Starting IV 0 1 2 3 4 5
Casting and splinting 0 1 2 3 4 5
Radiographic interpretation (initial) 0 1 2 3 4 5
Informed consent 0 1 2 3 4 5 Explanation to patient/family 0 1 2 3 4 5 Documentation 0 1 2 3 4 5 Venipuncture 0 1 2 3 4 5 Ultrasounds 0 1 2 3 4 5
Programs
Experience
OSHA (Occupational Safety and Health Administration) 0 1 2 3 4 5
Medicare and Medicaid 0 1 2 3 4 5
CLIA waiver (Clinical Laboratory Improvement Amendments) 0 1 2 3 4 5
TJC (The Joint Commission) 0 1 2 3 4 5
HEDIS (Health Plan Employer Data and Information Set) 0 1 2 3 4 5 DQIP (Diabetes Quality Improvement Program) 0 1 2 3 4 5 HIPAA (Health Insurance Portability & Accountability Act) 0 1 2 3 4 5
HCAHPS 0 1 2 3 4 5
Age Specific Competencies
Experience
Newborn/neonate (birth-30 days) 0 1 2 3 4 5
Infant (31 days-1 year) 0 1 2 3 4 5
Toddler (ages 2-3 years) 0 1 2 3 4 5
Preschool (ages 4-5 years) 0 1 2 3 4 5
School age (ages 6-12 years) 0 1 2 3 4 5
Adolescents (ages 13-21 years) 0 1 2 3 4 5
Young adult (ages 22-39 years) 0 1 2 3 4 5
Adults (ages 40-64 years) 0 1 2 3 4 5
Older adult (ages 65-79 years) 0 1 2 3 4 5
The information on this and all preceding pages is true and correct.
___________________________________________________________________________________________________
Signature
Date
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