* = Required Information
Last Name
*
First Name
*
Date
Please mark the corresponding experience level for each section
A - Able to perform without any supervision
B - Perform infrequently (Would require some supervision )
C - No experience (Require Assistance / Supervision )
A. GENERAL SURGERY
1. Cholecystectomy/Cholangiogram
A
B
C
2. Hemorrhoidectomy
A
B
C
3. Imperforate Anus Reconstruction
A
B
C
4. Radical Mastectomy
A
B
C
5. Tracheostomy
A
B
C
6. Vagotomy
A
B
C
7. Saphenous Vein Ligation and Stripping
A
B
C
8. Lumbar Sympathectomy
A
B
C
9. Hepatic Resection
A
B
C
10. Circumcision
A
B
C
11. Abdominal Perineal Resection
A
B
C
12. Adrenalectomy
A
B
C
13. Colectomy
A
B
C
14. Herniorrhaphy, femoral, inguinal
A
B
C
15. Pancreatectomy/Pancreatogram
A
B
C
16. Splenectomy
A
B
C
17. Whipple Procedure
A
B
C
18. Bowel Resection
A
B
C
19. Pilonidal Cystectomy
A
B
C
20. Hiatal Herniorraphy, transabdominal
A
B
C
21. Colostomy/Ileostamy
A
B
C
22. Anal Fissurectomy
A
B
C
23. Appendectomy
A
B
C
24. Gastrectomy
A
B
C
25. Organ Procurement
A
B
C
26. Portal Caval Shunt
A
B
C
27. Thyroidectomy
A
B
C
B. ORTHOPEDIC
1. Amputation: arm/leg
A
B
C
2. Insertion of McIntosh Tibial Plateau Prosthesis
A
B
C
3. Insertion of Swanson Finger Prosthesis
A
B
C
4. Tendon Transplants
A
B
C
5. Carpal Tunnel release
A
B
C
6. Putti Platt/Bankart Procedure
A
B
C
7. Spinal Fusion
A
B
C
8. Patellectomy
A
B
C
9. Heel Cord Lengthening
A
B
C
10. Bunionectomy
A
B
C
11. Application of Halo Traction
A
B
C
12. Capsularrhaphy
A
B
C
13. Laminectomy
A
B
C
14. Repair Hammer Toes
A
B
C
15. Application of Spica Cast
A
B
C
16. Excision of Olecrannon Bursa
A
B
C
17. Cup Arthroplasty/Insertion Prosthesis
A
B
C
18. Sharranrd Procedure
A
B
C
19. Nailing Proce
A
B
C
a. A-O
A
B
C
b. Lottes
A
B
C
c. Jewett
A
B
C
d. K Wires
A
B
C
e. Schneider
A
B
C
f. Kuntscher Rod
A
B
C
g. Rush
A
B
C
C. NEURO
1. Anterior Cervical Fusion
A
B
C
2. Laminectomy
A
B
C
3. Ulna Nerve Transplant
A
B
C
4. Craniectomy for Decompression Fracture
A
B
C
5. Burrholes for Subdural Hematoma
A
B
C
6. Meningocele Repair
A
B
C
7. Vinke Tong Insertion
A
B
C
8. Clipping of Intracranial Aneurysm
A
B
C
9. Carotid Ligation
A
B
C
10. Shunt Procedures; VP/VA/LP
A
B
C
11. Ventriculography Procedures
A
B
C
12. Cranioplasty
A
B
C
13. Crutchfield Tong Insertion
A
B
C
14. Cervical Sympathectomy
A
B
C
15. Hypophysectomy
A
B
C
16. Craniotomy
A
B
C
D. GYN
1. Hyserectomy, vaginal
A
B
C
2. Hysterectomy, abdominal
A
B
C
3. Termination of Pregnancy
A
B
C
4. Caesarean Section
A
B
C
5. Laser Surgery
A
B
C
6. Marsupialization Bartholin Cyst
A
B
C
7. Colpotomy
A
B
C
8. Radium Insertion
A
B
C
9. Vaginal Reconstruction
A
B
C
10. Dilation and Curettage
A
B
C
11. Vaginectomy
A
B
C
12. Tubal Ligation
A
B
C
13. Marchetti-Marshall
A
B
C
14. Shirodkar Operation
A
B
C
15. Salpingo-Oopherectomy
A
B
C
E. UROLOGICAL
1. Vasectomy
A
B
C
2. Cystectomy
A
B
C
3. Hypospedius Repair
A
B
C
4. Nephrectomy
A
B
C
5. Circumcision
A
B
C
6. Prostatectomy, perineal
A
B
C
7. Protstectomy, suprapubic
A
B
C
8. Kidney Transplant
A
B
C
9. T.U.R.
A
B
C
10. Orchietomy
A
B
C
11. Ureterolithotomy
A
B
C
12. Pyeoplasty
A
B
C
F. Thoracic/Cardiovascular
1. Closed Thoracotomy
A
B
C
2. Pericardiectomy
A
B
C
3. Tracheal Resection
A
B
C
4. Transthoracic Diaphragmatic Herniorrhaphy
A
B
C
5. Esophagectomy
A
B
C
6. Thoracoplasty
A
B
C
7. Mitral Commissurotomy
A
B
C
8. Closure Patent Ductus Arteriosis
A
B
C
9. Endocardial-Pacemaker Implantation
A
B
C
10. Myocaridal-Pacemaker Implantation
A
B
C
11. Correction Pectus Excavatum
A
B
C
12. Pnemunectomy/Lobectomy
A
B
C
13. First Rib Resection
A
B
C
14. Excision Cervical Rib
A
B
C
15. Revascularization Coronary Arteries
A
B
C
16. Heller Procedure
A
B
C
17. Resection Coarctation Aorta
A
B
C
18. Open Heart Procedure/CP Bypass
A
B
C
a. Septal Defect Repairs
A
B
C
b. Heart Valve Replacement
A
B
C
19. Aortic Femoral Bypass graft
A
B
C
20. Femoral Popliteal Bypass
A
B
C
21. Aortic Aneurysm w/graft replacement
A
B
C
22. Endoscopic Vein Harvesting
A
B
C
23. Cardiac Cath Lab-Intra-Aortic Balloon Pump
A
B
C
24. Septal Defects, ASV,VSD
A
B
C
25. Coronary Artery Bypass Graft
A
B
C
26. Off Pump Bypass
A
B
C
G. Vascular
1. Shunts
A
B
C
2. Vena Cava Ligation
A
B
C
3. Embolectomy
A
B
C
4. Angiography
A
B
C
5. A -V access grafts
A
B
C
6. Peripheral Vascular Bypass Procedures
A
B
C
7. Thrombectomy
A
B
C
8. Endarterectomy; carotid/femoral
A
B
C
9. Resection Carotid Aneurysm with Graft
A
B
C
H. Ear, Nose & Throat
1. Luc-Caldwell
A
B
C
2. Maxillary Advancement with Hip Graft
A
B
C
3. Selective Osteotomy of Maxilla/Mandible
A
B
C
4. Cammendo Procedure
A
B
C
5. Open Reduction Facial Fractures
A
B
C
6. Submuccus Resection
A
B
C
7. Fenestration Procedure
A
B
C
8. Parotidectomy
A
B
C
9. Tympanoplasty
A
B
C
10. Laryngectomy
A
B
C
11. Radial Neck Dissection
A
B
C
12. Cleft Lip-Palate Repair
A
B
C
13. Myringotomy
A
B
C
14. Sinusotomy
A
B
C
15. Ethymoidectomy
A
B
C
16. Open Reduction Nasal Fracture
A
B
C
17. Tonsillectomy
A
B
C
18. Frontal Flap Sinus Procedure
A
B
C
19. PE Tueb Insertion
A
B
C
20. Myringoplasty
A
B
C
21. Mastoidectomy
A
B
C
22. Ranulectomy
A
B
C
23. Closed Reduction Nasal Fracture
A
B
C
24. Nasal Ploypectomy
A
B
C
25. Stapedectomy
A
B
C
26. Excision Salivary Gland Tumor
A
B
C
27. Open Reduction Tripod Fracture
A
B
C
28. Tracheostomy
A
B
C
29. Glossectomy
A
B
C
30. Pharyngeal Flap Procedure
A
B
C
I. EYE
1. Pterygium Repair
A
B
C
2. Corneal Transplant
A
B
C
3. Ocutome
A
B
C
4. Dacryocystorlfinostomy
A
B
C
5. Microscope
A
B
C
6. Enucleation
A
B
C
7. Repair of Retinal Detachment
A
B
C
8. Orbital Implant
A
B
C
9. Phacoemulsifier
A
B
C
10. Repair Orbital Blowout Fracture
A
B
C
11. Dacryocystectomy
A
B
C
12. Cataract Extraction
A
B
C
13. Recession Resection
A
B
C
14. Diathermy Operation
A
B
C
15. Iridectomy
A
B
C
J. ORAL
1. Closed reduction factial fractures/wiring
A
B
C
2. Extraction of Impacted Molars
A
B
C
3. Extraction of Deciduous Teeth
A
B
C
4. Excision Odontoma
A
B
C
K. PLASTIC
1. Rhinoplasty
A
B
C
2. Mentoplasty
A
B
C
3. Blepheroplasty
A
B
C
4. Reduction Mammoplasty
A
B
C
5. Reconstructive
A
B
C
6. Augmentation Mammoplasty
A
B
C
7. Otoplasty
A
B
C
8. Cleft-Lip Palate Repair
A
B
C
9. Split Thickness Skin Grafting
A
B
C
10. Dermabrasion
A
B
C
11. Scar Revisions
A
B
C
12. Skin Grafting
A
B
C
13.Liposuction
A
B
C
L. Endoscopic
1. Gastroscopy
A
B
C
2. Sigmoidoscopy
A
B
C
3. Bronchoscopy
A
B
C
4. Laryngoscopy
A
B
C
5. Culdoscopy
A
B
C
6. Mediastinoscopy
A
B
C
7. Laparoscopy
A
B
C
8. Esophagoscopy
A
B
C
9. Cystoscopy
A
B
C
M. CARDIOVASCULAR RESUSCITATION
1. Intubation
A
B
C
2. Mouth to Mouth Resuscitation
A
B
C
3. Ambu
A
B
C
4. Cardiac Compression
A
B
C
N. Trauma
1. Motor Vehicle Accidents
A
B
C
2. Amputations
A
B
C
3. Gunshot/Stab wounds
A
B
C
4. Burns
A
B
C
O. INTRAVENOUS THERAPY
1. Medicut
A
B
C
2. Jelco
A
B
C
3. Intracath
A
B
C
4. Regular Intravenous Set
A
B
C
5. Scalp Vein
A
B
C
P. MISCELLANEOUS EQUIPMENT
1. Disposable Bovie Plates
A
B
C
2. K-Pad Unit
A
B
C
3. Pneumatic Tube System
A
B
C
4. Washer Sterilizer-AMSCO
A
B
C
5. Ultrasonic Cleanser-AMSCO
A
B
C
6. Washer Sanitizer--AMSCO
A
B
C
7. Flash Autoclave--AMSCO
A
B
C
8. Ethylene Oxide Sterilizer--AMSCO
A
B
C
9. Defibrillator-Datascope 680 Resuscitation
A
B
C
10. Aquamatic K Thermia Unit
A
B
C
11. Kiddie Pneumatic Tourniquet
A
B
C
12. Portable Light
A
B
C
13. Vaccum Curettage
A
B
C
14. Hemokinetitherm-Blood Warmer
A
B
C
15. Eye Magnet
A
B
C
16. Nitrous Oxide Bank
A
B
C
17. Auto Suture, TA 30, Stapling Instrument
A
B
C
18. Auto Suture, TA 55, Stapling Instrument
A
B
C
19. Auto Suture, TA 90, Stapling Instrument
A
B
C
20. Auto Suture, GIA, Stapling Instrument
A
B
C
21. Pleur-e-vac Units (Disp. Chest Drainage)
A
B
C
22. Vac-pac Positioner
A
B
C
23. Blood Bank Refrigerator
A
B
C
24. Emerson-Thoracic Pump
A
B
C
25. Nerve Stimulator
A
B
C
26. Portable Cardiac Monitor, Datascope 850
A
B
C
27. Cry-Opthalmic Unit
A
B
C
28. AOMI, Fiber Optic Luminator
A
B
C
29. PILLING, Fiber Optic Luminator
A
B
C
30. Orthopedic Arm Board with Drain
A
B
C
31. Bovie Electrosurgical Unit
A
B
C
32. Dual Tract Lights (bulb changing; handles)
A
B
C
33. Kreiselman Resuscitator
A
B
C
34. Steri-vac-neration Cabinet, 3-M, portable
A
B
C
35. Electrodyne-Cardiac Montior & Pacemaker
A
B
C
36. Conductometer
A
B
C
37. Operating Microscope
A
B
C
38. Cell Saver
A
B
C
39. Laser
A
B
C
40. Defibrillator-Electrodyne
A
B
C
41. Hall Neurotome
A
B
C
42. Nesq Graft
A
B
C
43. Operating Room Table, Castle 5 Section
A
B
C
44. Ohio Suction Units
A
B
C
45. Suction Unit, Disposable
A
B
C
46. Tele-thermometer
A
B
C
47. Compression Set, Zimmer
A
B
C
48. Drills
A
B
C
a. Smith Cranial
A
B
C
b. Hall Air Driver
A
B
C
c. Hall Dental
A
B
C
d. Chayes
A
B
C
e. Jordan Day
A
B
C
f. A-O
A
B
C
49. Dermatome
A
B
C
a. Cordless Davol Unit
A
B
C
b. Brown
A
B
C
c. Padgett
A
B
C
d. Castroviejo Electro-Kerotome
A
B
C
AGE EXPERIENCE
Indicate groups in which you have expertise in providing, age-appropriate nursing care.
0 - 30 Days
Yes
No
30 Days - 1 year
Yes
No
1 - 5 years
Yes
No
5 - 13 years
Yes
No
13 - 18 years
Yes
No
18 - 39 years
Yes
No
39 - 64 years
Yes
No
64 years +
Yes
No
The information that I have given is accurate and true to the best of my knowledge. I hereby authorize Pace Medical Staffing, Inc. to release same to her client health care facilities.
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