Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
  • AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (1 month to 1 year)
    Toddler (1 year to 3 years)
    Preschooler (3 years to 5 years)
    School Age Child (5 years to 12 years)
    Adolescents (12 years to 18 years)
    Young Adults (18 years to 39 years)
    Middle Adults (39 years to 64 years)
    Older Adults (64 years to 79 years)
    Elderly Adults (over 79+ years)
    SKILLED ENVIRONMENTS
    Acute Care/ Hospital
    Managed Care
    SNF/ Long Term Care
    Home Health
    Outpatient
    GENERAL/EXPERIENCE
    Written Communication Skills
    Verbal Communication Skills
    Basic Negotiation Skills
    Job Related Computer Skills
    Ability to Prioritize
    Ability to Educate through Different Methods (Cognitive, Affective, and Psychomotor)
    Possess Strong Leadership Skills
    Possess Clinical Knowledge
    Ability to Work Effectively in All Situations
    Ability to Critically Think and Problem Solve
    Up to Date on Clinical Evidenced Based Practices
    Monitoring and Evaluation
    Theories and Principles of Adult Learning
    Ability to Develop and Implement Relevant Nursing Curriculum
    Ability to Identify and Manage Educational Opportunities
    Ability to Delegate Appropriately