Cirrus Concept Consulting
REGISTERED NURSE & lICENSED pRACITICAL NURSE
WORK EXPERIENCE CHECKLIST-NURSING
ALL BLANKS MUST BE COMPLETE
Population Served (check all applicable):
___ Neonatal ___ Infant/Children (0-11) ___ Adolescent (12-18)
___ Adult ___ Geriatric
Include month/year
Adult ICU: ___yes ___no ________dates of experience
Neuro ICU: ___yes ___no ________dates of experience
CVICU: ___yes___ no ________dates of experience
Dialysis: ___yes ___no ________dates of experience
ER: ___yes ___no ________dates of experience
Tele Med: ___yes ___no ________dates of experience
Tele Cardiac: ___yes ___no ________dates of experience
Med/Surg: ___yes ___no ________dates of experience
Rehab: ___yes ___no ________dates of experience
Psych: ___yes ___no ________dates of experience
Burn Unit: ___yes ___no ________dates of experience
OR: ___yes ___no ________dates of experience
Oncology: ___yes ___no ________dates of experience
PICU: ___yes ___no ________dates of experience
NICU: ___yes ___no _______dates of experience
Pediatrics: ___yes ___no ________dates of experience
Psych Peds: ___yes ___no ________dates of experience
OB: ___yes ___no ________dates of experience
Nursery: ___yes ___no ________dates of experience
L&D: ___yes ___no ________dates of experience
Level II nursery: ___yes ___no ________dates of experience
Ventilators: ___yes ___no ________dates of experience
Ortho: ___yes ___no ________dates of experience
Hospice: ___yes ___no ________dates of experience LTC: ___yes ___no ________dates of experience
Private Duty: ___yes ___no ________dates of experience
Home Health: ___yes ___no ________dates of experience
H/H Infusion: ___yes ___no ________dates of experience
Intermittent Skilled Visit: ___yes ___no _______dates of experience
Computer Charting: ___yes ___no _______dates of experience
Balloon pump: ___yes ___no _______dates of experience
Epidurals: ___yes ___no _______dates of experience
Basic Recognition of EKG arrhythmias: ___yes ___no _______dates of experience
Use of emergency equipment: ___yes ___no _______dates of experience
Blood Glucose Monitor Type: __________________________
For nurses assigned to special care units, proficiency in intensive or care and competency in:
The recognition, interpretation, and recording of signs and symptoms in critically ill patients: ___yes ___no
The parenteral administration of electrolytes and fluids: ___yes ___no
Prevention of contamination and cross-infection as covered in the Universal Precautions annual in-service ___yes ___no
The exercise of appropriate safety precautions in the use of electrical and electronic equipment as covered in fire/electrical safety annual in-service: ___yes ___no
Electronic Medical Record Training ___yes ___no Name of system-trained on:
___________________________
________________________________ ________________________________
Agency Employee Signature and Date Agency Administrative Signature/Date