LTAC RN

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CNA

Director of Nursing

LPN

MDS Coordinator

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LTC RN

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Antepartum Postpartum Nursery

Behavioral Health RN

Case Management

Cath Lab RN

Certified Surgical First Assistant

CVICU RN

CVOR RN

CVOR Surgical Tech

Dialysis RN

Endoscopy RN

Endoscopy Tech

ER RN

High Risk Skills

Home Health RN

Infection Prevention RN

Intensive Care RN

Infusion RN

LDRP RN

LTAC RN

Maternal Fetal/High Risk

Medical Surgical / Telemetry

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Nurse Manager

OB Tech

Oncology

OR RN

OR/Surg Tech

PACU

Pediatric Emergency Room

Pediatric Intensive Care

Pediatric RN

Sterile Processing Technologist

Surgical Tech

Tele, PCU, Stepdown RN

Transplant Coordinator RN

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Home Health Clinical Manager

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Home Health RN

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Hospice RN

Cath

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Dosimetrist

Echo

High Risk Skills

Histotechnologist

Interventional Skills

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MRI Technologist

Nuclear Medicine Technologist

OR/Surg Tech

Pharmacist

Pharmacy Technician

Radiologic Technologist

Radiation Therapist

Sterile Processing Tech

Ultrasound Tech

Vascular Ultrasound

Cytotechnologist

Histotechnologist

Medical Laboratory Technologist

Medical Technologist

Pathologist Assistant

Phlebotomy

Cath Lab RN

Cath Lab Technologist

Cath EP

Interventional Skills

Anesthesia Tech

Dietician

EKG Tech

Perfusionist

Polysomnographer / RPSGT

Respiratory Therapist

This self evaluation is for assessing your experience in specific clinical areas. This self evaluation will not be a determining factor in accepting your application to become an employee of Marvel Medical Staffing.
- 0 = Not Applicable
- 1 = No Experience
- 2 = Some Experience
- 3 = Intermittent Experience
- 4 = Experienced
- 5 = Very Experienced
*Required Field
AGE OF PATIENTS CARED FOR

0 1 2 3 4 5

0 1 2 3 4 5

Proficiency Rating Frequency Rating
Young Adults (18 years to 39 years)*
Middle Adults (39 years to 64 years)*
Older Adults (64+ years)*

CLINICAL SETTINGS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Hospital within Hospital*
Free - Standing LTAC*

GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Admission*
Advance Directives*
Collect Appropriate Data*
Organ / Tissue Donation*
Patient and Family Teaching*
Electronic Medical *

CARDIOVASCULAR

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

Abnormal Heart Sounds / Murmurs*
Capillary Refill*

Patient Experience

Acute MI*
Angina*
Cardiac Arrest / CPR*
Cardiomyopathy*
Congestive Heart Failure*
Pacemaker*
AICD (Automatic Implanted Cardioverter / Defibrillator)*
Post Cardio - Thoracic Surgery*

Monitoring

CVP Monitoring*
Arterial Line*
Cardiac Monitoring*

Labs

BNP (Brain Natriuretic Peptide)*
Cardiac Enzymes and Isoenzymes*
Coagulation Studies*
Troponin*

PULMONARY

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

Adventitious Breath Sounds*
Oxygenation Status*
Rate and Work of Breathing*

Patient Experience

Acute Pneumonia*
Chest Tube*
COPD*
Pulmonary Edema*
Pulmonary Embolism*
Tracheostomy*
Tuberculosis*

Monitoring

Pulse Oximetry*
End Tidal CO2*

Labs

ABGs*

NEUROLOGY

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

Level of Consciousness*
Neuro Assessment*
Reflex / Motor Deficits*
Visual / Communication Deficits*

Patient Experience

Alzheimers Disease*
Coma*
CVA / Stroke*
Neuromuscular Disease*
Seizure Disorder*
Spinal Cord Injury*
Traumatic Brain Injury*
Halo Traction / Cervical Tongs*

GASTROINTESTINAL

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

Nutritional Status*
Bowel Sounds*
GI Assessment*

Patient Experience

Abdominal Wounds*
Bowel Obstruction*
Colostomy*
GI / Esophageal Bleeding*
Hepatitis*
Pancreatitis*
Liver Failure*
Cancer*

Labs

Serum Amylase*
Serum Ammonia*
Liver Function Tests*

RENAL / GENITOURINARY

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

Fluid Status*

Patient Experience

Acute Renal Failure*
End Stage Renal Failure*
Hemodialysis*
Nephrostomy*
Urinary Tract Infection*
Suprapubic Cath*
Fistula / Shunt*

Monitoring

I &O Measurment*
Fluid Balance*

Labs

Serum Electrolytes*
BUN and Creatinine*

ENDOCRINE / METABOLIC

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Patient Experience

Diabetes*
Blood Glucose*

MUSCULOSKELETAL

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

Pulse / Circulation Checks*

Patient Experience

Amputation*
Joint Replacement*
Skeletal / Skin Traction*
Cast Care*

IMMUNOLOGY / HEMATOLOGY / ONCOLOGY

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Patient Experience

Cancer*
HIV / AIDS*
Treatment Side Effects - Chemo / Radiation*
Sepsis*

WOUNDS / INTEGUMENT

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess

S/S Infection*
Staging of PRessure Ulcers*
Skin Assessment*

Patient Experience

Burns*
Pressure Ulcers*
Surgical Wounds and Drains*
Statis Ulcers*
Wounds*

Monitoring

Skin Breakdown*

MEDICATION / THERAPEUTIC INTERVENTIONS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Medication Administration

Administer IM and SQ Meds*
Administer PO Medications*
Administer IVP Medications*
Administer IVPB Medications*
Administer IV Drips and Titration*
Administer Meds per Feeding Tubes*

IV Therapy

Assess / Maintain IV*
Heparin Lock*
Vascular Access Device - Care / Maintenance*
Peripheral IV Insertion*

Blood

Administer Blood / Blood Products*

Nutrition Therapy

Enteral Feeding Administration*
TPN / Procalamine*
Tube Feeding Pumps*
Bolus Tube Feedings*
NGT / SBFT Insertion*
PEG / G-Tube*

Oxygen Administration

Nasal Cannula*
Venti Mask*
Non - Rebreather Mask*
Ambu - Bag*
Trach Collar*
Portable Oxygen Ventilator (IMV, AC, PEEP)*

Pain Management

Assess Pain Level Tolerance*
Functional Pain Goal*
Epidural Analgesia*
Patient Controlled Analgesia*

PROCEDURES / EQUIPMENT

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Perform / Maintain

Chest Tube Drainage Systems*
Doppler*
Dressing Changes*
Drains (JP - Hemovac - Penrose)*
Suctioning (Oral - Naso - Pharnyx)*
Tracheostomy Care / Suctioning*
Indwelling Urinary Catheter*
Isolation*
Wound Vac*
Wound Care / Irrigations*

Specimen Collections

Finger Stick*
Butterfly Stick*
Central - Line Blood Draw*
Clean Catch Urine*
Urine Catheter Culture Collection*
Blood Cultures*
Venipuncture*
24 Hour Urine*

Assist

Bedside Invasive Procedures*
Bronchoscopy*
Central Line Insertion*
Chest Tube Insertion*
Endotracheal Intubation*
Procedure / Moderate Sedation*
Application Agreement*
- I certify that the test was filled out to the best of my knowledge.
Signature*
Date*
First Name*
Last Name*
Applicant Email*
Applicant Phone*

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