LTC RN

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Director of Rehab

OT

COTA

PT

PTA

SLP/SLPA

CNA

Director of Nursing

LPN

MDS Coordinator

Medication Aide

LTC RN

Ambulatory RN

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

Neonatal Intensive Care

Nurse Manager

OB Tech

Oncology

OR RN

OR/Surg Tech

PACU

Pediatric Emergency Room

Pediatric Intensive Care

Pediatric RN

Rehab RN

Sterile Processing Technologist

Surgical Tech

Tele, PCU, Stepdown RN

Transplant Coordinator RN

Home Health Case Manager

Home Health Clinical Manager

Home Infusion RN

Home Health LPN

Home Health RN

Hospice LPN

Hospice RN

Cath

CT Tech

Dosimetrist

Echo

High Risk Skills

Histotechnologist

Interventional Skills

Mammography Skills

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
Newborn/Neonate (birth - 30 days)*
Infant (30 days - 1 year)*
Toddler (1 - 3 years)*
Preschooler (3 - 5 years)*
School Age Child (5 - 12 years)*
Adolescents (12 - 18 years)*
Young Adults (18 - 39 years)*
Middle Adults (39 - 64 years)*
Older Adults (64 - 79 years)*
Elderly Adults (over 79+ years)*

GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Standard Precautions*
Isolation Precautions*
Pediatric Respiratory/ Cardiac Arrest*
Adult Respiratory/ Cardiac Arrest*
Crash Carts*
Defibrillators*
Care of Patients in Restraints*
Pain Management*
Automated Med Dispensing System*
List Types:
Care Planning & Discharge Planning*
Patient/ Family Education*
Electronic Documentation*
List Types:
Patient Head to Toe Assessment*

MEDICATION-KNOWLEDGE AND USE OF

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Pouring from Stock Medications*
Narcotic Administration*
IV Push/ Drip Medications*
Antibiotics*
Oral*
Topical*
Otic*
Rectal*
Vaginal*
Ophthalmic*
Continuous Subcutaneous Infusion Pumps*
Total Parenteral Nutrition (TPN)*
Peripheral Parenteral Nutrition*
Patient Controlled Analgesia (PCA)*

PHLEBOTOMY/ IV THERAPY

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Blood Draw - Peripheral*
Blood Draw - Central Line/Port*
Insertion, Care and Maintenance of Peripheral IV*
Care and Maintenance of Central Lines*
Care and Maintenance of Implanted Port- A- Cath*
Mixing IVs*
Regulating IVs*
IV Infusion Pumps*
Blood/Blood Product Administration*

CARDIAC

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Recognizing Basic & Life- Threatening Dysrhythmia*
Congestive Heart Failure*
Pulse Checks*
Use of Doppler Cardiac Monitors*
Taking EKGs- 12 Lead*
Use of Automatic BP Cuff (ie Dinamap)*

Care of Patient With:

Heart Failure*
CHF*
MI*
Arrhythmias*
Hypertension*
Hypotension*
CAD*

Knowledge and Use of:

Anticoagulants*
Nitrates (Oral, Topical)*
Antiarrhythmics (Oral)*
Antihypertensives (Oral)*

RESPIRATORY

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

COPD*
Asthma Exacerbation*
Tracheostomy*
Pneumonia*
Emphysema*
Pre/ Post Thoracic Surgery*
Chest Tubes*
Collection of Sputum Specimen*
O2 Cannulas/ Masks*
Non- rebreather Mask*
Nebulizer Set- up/ Use*
Incentive Spirometry*
Chest PT*
Suctioning (Oral/ Nasotracheal)*
Suctioning (Tracheostomy Tube)*
Ventilator Patient (Mouth Care, Suctioning, Ambu bag)*

Knowledge and Use of

Bronchodilators (Oral, IV, Inhaler)*
Steroids*

NEURO

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Spinal Cord Injury - Acute*
Spinal Cord Injury - Long Term*
CVA/Stroke*
Neuromuscular Disease*
Alzheimers Disease*
Wandering*
Hallucinations*
Anxiety*
Agitation*
Reality Orientation*
Assessing Levels of Consciousness*
Pupil Checks*
Seizure Precautions*
stroke_precautions*
Swallow Precautions*
Assisting with Lumbar Puncture*
Use of Hyper/Hypothermia Blanket*

Knowledge and Use of:

Anticonvulsant*
Sedative*

SENSORY DEFICITS-CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Dentures*
Hearing Aids*
Hearing Loss*
Prosthetic Eye*
Contact Lens Care*
Blindness*
Macular Degeneration*

GASTROINTESTINAL - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Nasogastric Tubes (i.e. Salem Sump, Levine)*
Nasointestinal Tubes (i.e. Cantor, Miller- Abbott)*
Jejunostomy, Gastrostomy, Cecostomy Tubes*
Colostomy, Ileostomy*
Bronchoscopy Lung/Wedge Resection*

GI GENERAL

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Collection of Stool Specimens*
Bowel Preparation and Cleansing Procedures*
Administration of Tube Feedings via Flexible Tubes*
Bowel Disimpaction*
Bowel Retraining*
Sitz Bath Treatments*
Insertion and Checking Placement/Patency NG Tubes*

ENDOCRINE - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Diabetes*
Hyper/Hypoglycemia*

ENDOCRINE GENERAL

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Blood Glucose Monitoring*
Performing Fingersticks*
Use of Blood Glucose Meter Device*
Use of Visual Blood Glucose Strips*

Knowledge and Use of:

Single Type Insulin*
Mixed Insulins*
Insulin Infusion*

RENAL/GU - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Incontinence*
Urinary Retention*
UTI*
Insertion of Foley Catheter - Female*
Insertion of Foley Catheter - Male*
Straight Catheterization - Male*
Straight Catheterization - Female*
Insertion of Suprapubic Catheter*
Application of Condom Catheter*
Bladder Retraining*
Urinary Diversion*
Bladder Irrigation (Continuous and Intermittent)*

Peritoneal Dialysis

Manual*
Automatic Cycler Machine*

ORTHOPEDIC- CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Total Joint Replacement*
Rheumatic/Arthritic Disease*
Amputation*
Fracture*

ORTHOPEDIC GENERAL

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Cast Care*
CMS Checks*
Traction - Skin*
Traction - Skeletal*
Range of Motion*
Use of Assistive Devices*
Application of Splints of Extremities*
Continuous Passive Motion Machine (CPM)*
Transfer Techniques*
Use of Sliding Board*
Gait Training/ Retraining*
Application of Prosthetic Devices*
Application of Orthotic Devices*

WOUND/ SKIN- CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Pressure Sores*
Leg Ulcers*
Burns*

WOUND/SKIN GENERAL

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Acute Dressing Changes*
Wound Care*
Irrigations*
Identifying Common Skin Problems*
Recognizing Normal Skin Changes*
Use of Special Pressure Relief Devices*
Pressure Relief Mattress/Seat Cushion*

ADDITIONAL SKILLS- CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Hemovacs*
Jackson-Pratt Tubes*
Penrose Drains*
T-Tubes*
Wound Vac*
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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