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 SKILLS
    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
    Foster Individualized Learning
    Facilitate clinical reasoning among diverse learners who may have different learning styles and unique learning needs
    Plan, select, design and implement teaching and learning strategies, materials and resources to achieve educational goals and outcomes
    Act as a role model for the teaching and provision of ethical and legal nursing practice
    Demonstrate cultural competence in teaching and nursing practice
    Facilitate proessionalism and support the professional learning of colleagues
    Act as a resource and provide a safe learning space
    SPECIALTY EXPERIENCE
    ER
    ICU
    MICU
    SICU
    TICU
    PICU
    NICU
    OR
    Med-surg
    Post-partum
    High Risk Perinatal
    Telemetry
    PACU
    Oncology
    Pediactrics
    Psychiatry
    Dialysis
    Coronary/Cardiac Care Unit
    Palliative Care or Hospice
    Rehabilitation
    Step-down Unit
    Orthopedics
    Pulmonary
    GI
    Geriatric
    Neurology
    Other: