Rehab 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 SPECIFIC CARE

0 1 2 3 4 5

0 1 2 3 4 5

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

SETTING

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Hospital*
Long Term Care*
Long Term Acute Care*
Skilled Nursing Units*
Rehab*

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/External Pacing*
Automated Med Dispensing Systems*
List Types:
Care Planning & Discharge Planning*
Patient/Family Education*
Electronic Documentation (EMR)*
List Types:
Patient Assessment (Obtain Patient History)*
IV Pumps*
Advance Directives*
Sterile and Aseptic Technique*
Obtaining Vital Signs*
Transfer of Patient*
Suture/Staple Removal*
Care of Patients in Restraints*
Peripheral IV Insertion, Care, and Maintenance*
Access/Management of Implanted Ports*
Access/Management of Central Lines*
PCA/Epidural Pumps*
Titration of Drips*
Administration of Blood/Blood Products*

PROCEDURES

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Blood Cultures*
Dipstick Urine*
Sputum*
Sterile Urine*
Stool*
Throat Swab*
Venipuncture*
IM and SQ Injections*

ASSIST WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Bedside Invasive Procedures*
Intubation*
Lumbar Puncture*

CARDIOVASCULAR - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Abnormal Heart Sounds/Murmurs*
Auscultation (Rate/Rhythm)*
Capillary Refill*
Color*

CARDIOVASCULAR - CARE OF PATIENT WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Acute Myocardial infraction*
Angina*
Cardiac Arrest/Cardiopulmonary Resuscitation*
Cardiomyopathy*
Congestive Heart Failure*
Permanent Pacemaker*
Internal Defibrillator*
Cardiac Transplant*
Pre/Post Cardiac Surgery*
Abdominal Aortic Aneurysm/Bypass*
Femoral Popliteal Bypass*
Myocarditis*
Post Angioplasty/Stent*
Thrombophlebitis*
Chest Pain*

CARDIOVASCULAR - MONITORING LABS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

EKG Monitoring*
Cardiac Enzymes and Isoenzymes*
Coagulation Studies*
BNP*
Troponin*

PULMONARY - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Assess Lung Sounds*
Rate and Work of Respirations*
Oxygenation Status*
Oxygen Delivery Devices*

PULMONARY - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Asthma*
Bronchoscopy*
Chest Trauma*
Chest Tubes*
COPD*
Laryngospasm*
Lobectomy*
Lung Transplant*
Obstructive Sleep Apnea*
Pre/Post Thoracic Surgery*
Pneumonectomy*
Pneumonia*
Pneumothorax*
Pulmonary Edema*
Pulmonary Embolism*
Thoracotomy*
Tracheostomy*
Tuberculosis*

PULMONARY - MONITORING LABS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Pulse Oximetry*
Interpretation of ABGs*

NEUROLOGICAL - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

PERRL*
Level of Consciousness*
Neurological Assessment*
Reflex/Motor Deficits*
Visual/Communication Deficits*
Stroke Precautions*

NEUROLOGICAL - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Alzheimer’s Disease*
Coma*
CVA*
Halo Traction/Cervical Tongs*
Intracranial Hemorrhage*
Laminectomy*
Neuromuscular Disease*
Post Craniotomy*
Seizure Disorder*
Spinal Cord Injury*
Pre/Post Neurosurgery*
Closed Head Injuries*
Delirium Tremens*
Meningitis*
Overdose*
Guillain Barre Syndrome*
Externalized AV Shunt*

GASTROINTESTINAL - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Bowel Sounds*
Nutritional Status*
GI Assessment*
GT/PEG Feedings*

GASTROINTESTINAL - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Abdominal Wounds and Surgeries*
Bowel Obstruction*
Colostomy*
GI Bleeding*
Hepatitis*
Ileostomy*
Pancreatitis*
Paralytic Ileus*
Post Abdominal Surgery*
Liver Transplant*
Inflammatory Bowel Disease*
Liver Failure*
Abdominal Trauma*

RENAL/GENITOURINARY - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Fluid Status*

RENAL/GENITOURINARY - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Acute Renal Failure*
End Stage Renal Disease*
Hemodialysis*
Peritoneal Dialysis*
Urinary Tract Infection*
Suprapubic Catheter*
Kidney Transplant*
Insertion of Catheter (Straight/Foley)*
Bladder Irrigations*
AV Fistula/Shunt Care*
Nephrostomy Tube*
Nephrectomy*
Pyelonephritis*
TURP*
Ileal Conduit*
Renal Trauma*
Renal Calculi*

RENAL/GENITOURINARY - MONITORING/LABS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Measurement of I & O*
Fluid Balance*
BUN and Creatinine*
Serum Electrolytes*

ENDOCRINE/METABOLIC - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Diabetes Mellitus*
Diabetes Insipidus*
Keto Acidosis*
Diabetic Coma*
Hyperthyroidism*
Thyroidectomy*

ENDOCRINE/METABOLIC - MONITORING/LAB

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Blood Glucose*

ENDOCRINE/METABOLIC - KNOWLEDGE AND USE OF

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Single Type Insulin*
Mixed Insulins*
Insulin Infusion*

ORTHO/MUSCULOSKELETAL - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Pulses/Circulation Checks*
Cast Care*
Crutch Walking*
Traction*
Prosthesis Application*
Assistive Devices*

ORTHO/MUSCULOSKELETAL - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Amputation*
External Fixation*
Multiple Trauma*
Paraplegia*
Rheumatoid Arthritis Disease*
Joint Replacement*
Open Reduction Internal Fixation*
Fractures*
Spinal Fusion*
Amputation*

IMMUNOLOGY/HEMATOLOGY/ONCOLOGY - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Blood Transfusions*

IMMUNOLOGY/HEMATOLOGY/ONCOLOGY - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Cancer*
HIV/AIDS*
Sickle Cell Anemia*
Acute Leukemia*
Treatment Side Effects*
Chemotherapy*
CRE*
MSRA*
C. Difficile*
Influenza*
Radiation*
Sepsis*

IMMUNOLOGY/HEMATOLOGY/ONCOLOGY - LAB

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Hematology*

WOUND/INTEGUMENT - GENERAL SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

S/S Infection*
Skin Assessment*
Dressing Changes*
Stump Wrapping*

WOUND/INTEGUMENT - CARE OF PATIENTS WITH

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Burns and Stages*
Staged Decubitus Ulcers*
Stasis Ulcers*
Arterial Ulcers*
Suspected Deep Tissue Injuries*
Multiple Abdominal Wounds and Drains*
Gunshot Wound*
Stab Wound*
Lacerations*
Pressure Relief Mattresses*
Traumatic Wounds*
First Degree Burns*
Second Degree Burns*
Third Degree Burns*

WOUND/INTEGUMENT - EQUIPMENT

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Hemovacs*
Jackson-Pratt Drains*
Penrose Drains*
Surgical Wound Irrigations and Dressings*

WOUND/INTEGUMENT - MONITORING

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Skin Breakdown*

WOUND/INTEGUMENT - MEDICATIONS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Antibiotics*
Antihypertensives*
Anticoagulants*
Anticonvulsants*
Narcotics*
Digoxin*
Diuretics*
Steroids*
Diltiazem*
Antiemetics*
Antispasmodics*
Oral Hypoglycemics*
Inhalers*
IV Conscious Sedation*
Reversal Agents (Narcan, Romazicon)*

OTHER SKILLS

0	1	2	3	4	5

0	1	2	3	4	5

Proficiency Rating	Frequency Rating

Please List:
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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rehab-rn

Rehab RN