CRNA SKILLS CHECKLIST
Name:
When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill.

The scale is as follows:
1. Not performed   2. Intermitten experience   3. Very experienced.
Education and Certification:
Nursing School:
Location:
Year Completed:    Degree Obtained
Anesthesia School:
Location:
Year Completed:    Degree Obtained
Other Education:
Location:
Year Completed:    Degree Obtained
AANA Cert #:
Date of Certification:
States Licensed:
Pending Licenses:


GENERAL ANESTHESIA AND ANALGESIA
  1. Pre-Peri-Post Operative Prep & Medicati   1 2 3
  2. Intravenous Agents   1 2 3
  3. Intramuscular Agents   1 2 3
  4. Inhalation Agents   1 2 3
  5. Other: ________________________   1 2 3
    PROCEDURES
    1. Intravenous Catheter Placement   1 2 3
    2. Intravenous Administration of: _____   1 2 3
    3. Blood   1 2 3
    4. Cardiac Drugs   1 2 3
    5. Fluids   1 2 3
    6. Muscle Relaxants   1 2 3
    7. Plasma   1 2 3
    8. Plasma Expanders   1 2 3
    9. Vasoactive Drugs   1 2 3
    10. Other: ________________________   1 2 3
      1. Auto Transfusion Techniques   1 2 3
      2. Hypo/Hypertensive Techniques   1 2 3
      3. Hypothermia   1 2 3
      4. Mechanical Ventilation   1 2 3
      5. Placement of Arterial Lines   1 2 3
      6. Placement of Central Venous Lines   1 2 3
      7. Placement of Swan-Ganz   1 2 3
      8. Resuscitation Techniques   1 2 3
      9. BLS Certified   1 2 3
      10. ACLS Certified   1 2 3
      11. PALS Certified   1 2 3
      12. NRP Certified   1 2 3
      13. Other: ________________________   1 2 3
        Regional Anesthesia
        1. Epidural & Caudal   1 2 3
        2. Field Blocks   1 2 3
        3. Infiltration   1 2 3
        4. Intravenous   1 2 3
        5. Lower Extremities   1 2 3
        6. Upper Extremities   1 2 3
        7. Spinal   1 2 3
        8. Topical   1 2 3
        9. Other Peripheral Blocks   1 2 3
        10. Other: ________________________   1 2 3
          SPECIALTIES OR SPECIFIC SKILLS
          1. ENT   1 2 3
          2. Eyes   1 2 3
          3. General Surgery   1 2 3
          4. GYN   1 2 3
          5. Neuro   1 2 3
          6. OB   1 2 3
          7. Open Heart   1 2 3
          8. Ortho   1 2 3
          9. Pain Management   1 2 3
          10. Pediatrics   1 2 3
          11. Thoracic   1 2 3
          12. Transplants   1 2 3
          13. Trauma/Burns   1 2 3
          14. Urology   1 2 3
          15. Vascular   1 2 3
          16. Other: ________________________   1 2 3
            THERAPEUTIC BLOCKS
            1. Epidural   1 2 3
            2. Field Blocks   1 2 3
            3. Spinal-Differential   1 2 3
            4. Steroid, Alcohol, and Drug Phenol Block   1 2 3
            5. Sympathetic Blocks   1 2 3
            6. Other: ________________________   1 2 3
              The information I have given is true and accurate to the best of my knowledge. Please sign and date below.
              SIGNATURE: (Last 4 digits of your SSN)    Reenter your last 4 digits of your SSN:   DATE:

                
              Email:jobs@staffhospital.com  P.O.Box 225216 S.F. CA 94122 Tel:(866)713-4405 Fax:(866)232-3799
              Powered by Miphras Database and Web Services. All Rights Reserved.