Operating Room Nursing Skills Checklist

Name
Last 4 of SSN
Email ID
Date

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

EMR Conversion Yes No

	CERTIFICATIONS	Expiry Date
	BLS
	NRP
	PALS
	Certified Nurse Operating Room
	Registered Nurse First Assist

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