My responses in this checklist represent a true reflection of my experience and comfort level.
Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.
Typed Name (typing your name below serves as an electronic signature)* Date*
Phone*
My Recruiting
Professional at Health Source Group is:
Certifications:(Check all that apply)
BLS/BCLS/CPR:
MAB:
Level of Comfort/Experience
N/A=Non-applicable
1=Inexperienced in this area
2=Limited comfort/experience in this area
3=Comfortable/experienced in this area
4=Very comfortable/highly experienced in this area
Area
Not Applicable
Inexperienced
Limited
Experienced
Highly Experienced
Psychiatric
Adolescent
N/A
1
2
3
4
Adult
N/A
1
2
3
4
Geriatric
N/A
1
2
3
4
Suicidal risk assessment
N/A
1
2
3
4
Administration of psychotropic medications
N/A
1
2
3
4
Charge nurse experience
N/A
1
2
3
4
Contact precautions
N/A
1
2
3
4
Discharge patient AMA
N/A
1
2
3
4
DSM IV diagnosis
N/A
1
2
3
4
Emergency custody order
N/A
1
2
3
4
Group therapy leader
N/A
1
2
3
4
Management of assaultive behavior
N/A
1
2
3
4
Management of alcohol withdrawal symptoms
N/A
1
2
3
4
Management of Narcotic withdrawal symptoms
N/A
1
2
3
4
Management of violent patient
N/A
1
2
3
4
Patient rights
N/A
1
2
3
4
Psychiatric emergency response team
N/A
1
2
3
4
Rapid tranquilization
N/A
1
2
3
4
Restraints, application and assessment of
N/A
1
2
3
4
Telephonic crisis intervention
N/A
1
2
3
4
Therapeutic communication skills
N/A
1
2
3
4
Eating disorder
N/A
1
2
3
4
Hallucinations
N/A
1
2
3
4
Lithium toxicity
N/A
1
2
3
4
Manic-depression
N/A
1
2
3
4
OD
N/A
1
2
3
4
Substance abuse
N/A
1
2
3
4
Schizophrenia
N/A
1
2
3
4
Seclusion
N/A
1
2
3
4
Suicidal behavior
N/A
1
2
3
4
Cardiovascular
Basic 12 lead EKG interpretation
N/A
1
2
3
4
Defibrillation/cardioversion
N/A
1
2
3
4
Care of the patient with CHF (congestive heart failure)
