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Operating Room Skills Checklist

*required fields

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. NOTE THAT SECTIONS ARE SEPARATELY DISPLAYED FOR CIRCULATE AND SCRUB.

 

Typed Name (typing your name below serves as an electronic signature) *      Date*

                                                         

 

Phone*

           

 

 My Recruiting Professional at Health Source Group is: 

 

Level of Comfort/Experience

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

General Surgery: Circulate

Appendectomy

N/A  

1

2

3

4

Breast Biopsy

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Abdominal-Perineal Resection

N/A  

1

2

3

4

Bowel/Colon Resection

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Thyroidectomy

N/A  

1

2

3

4

Splenectomy

N/A  

1

2

3

4

Vein Stripping

N/A  

1

2

3

4

Radical Mastectomy

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Gastrectomy

N/A  

1

2

3

4

Hickman/Groshong/Portacath Insertion

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Bowel

N/A  

1

2

3

4

Nissen

N/A  

1

2

3

4

Bariatric

N/A  

1

2

3

4

 

General Surgery: Scrub

Appendectomy

N/A  

1

2

3

4

Breast Biopsy

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Abdominal-Perineal Resection

N/A  

1

2

3

4

Bowel/Colon Resection

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Thyroidectomy

N/A  

1

2

3

4

Splenectomy

N/A  

1

2

3

4

Vein Stripping

N/A  

1

2

3

4

Radical Mastectomy

N/A  

1

2

3

4

Tracheostomy

N/A  

1

2

3

4

Gastrectomy

N/A  

1

2

3

4

Hickman/Groshong/Portacath Insertion

N/A  

1

2

3

4

Cholecystectomy

N/A  

1

2

3

4

Hernia Repair

N/A  

1

2

3

4

Bowel

N/A  

1

2

3

4

Nissen

N/A  

1

2

3

4

Bariatric

N/A  

1

2

3

4

 

Thoracic/CV: Circulate

Abdominal Aortic Aneurysm

N/A  

1

2

3

4

Aortic-Femoral Bypass Graft

N/A  

1

2

3

4

AV Shunt/Graft

N/A  

1

2

3