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)
  • First Assist EXPERIENCE WITH THE FOLLOWING AGES
    Newborn/Neonate (birth to 30 days)
    Infant 31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Time Out Procedure Pre-Op
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    GENERAL SURGERY-FIRST ASSIST WITH FOLLOWING
    Abdominal Perineal Resection
    Bowel Resection
    Cholecystectomy
    Gastrectomy
    Herniorrhaphy-Femoral/Inguinal, ventral, umbilical
    Hiatal Herniorrhaphy-Transabdominal
    Laparoscopic General Surgeries
    Organ Procurement
    Radical Mastectomy
    Breast biopsy
    Appendectomy
    Gastric Bypass
    Splenectomy
    Thyroidectomy
    Tracheostomy
    LAPAROSCOPIC PROCEDURES-FIRST ASSIST WITH FOLLOWING
    Cholecystectomy
    Appendectomy
    Hysterectomy
    Hernia Repair
    Colon Resection
    GYNECOLOGY-FIRST ASSIST WITH FOLLOWING
    Cesarean Section
    Dilation & Curettage
    Hysterectomy-Vaginal
    Hysterectomy-Abdominal
    Laser Surgery
    Salpingo-Oopherectomy
    Tubal Ligation
    Vaginectomy
    Vaginal Reconstruction
    G.U. AND CYSTO-FIRST ASSIST WITH FOLLOWING
    Circumcision
    Cystoscopy/Cystostomy
    Cystectomy
    Hypospadius Repair
    Lithotripsy
    Nephrectomy
    Orchiectomy
    Penile Implant
    Prostatectomy
    Ureterolithotomy
    T.U.R.P./T.U.R.B.
    Vasectomy
    ORTHOPEDIC-FIRST ASSIST WITH FOLLOWING
    Anterior Cruciate Ligament Reconstruction
    Carpal Tunnel surgery
    Arthroscopy/Arthrotomy
    Closed Pinning & Reduction of Extremities
    External Compression Devices
    Total Joint Replacement - Knee, Hip
    Spinal Fusion-Harrington Rods
    Spica Cast Application
    O.R.I.F.-Shoulder, Hip, Humerus etc.
    Patellectomy
    Tendon Implants & Reanastomosis
    NEUROSURGERY-FIRST ASSIST WITH FOLLOWING
    Anterior Cervical Fusion
    Burrholes for Subdural Hematoma
    Craniotomy
    Laminectomy
    Shunt Procedures-VP/VA
    PLASTICS-FIRST ASSIST WITH FOLLOWING
    Abdominoplasty/Abdominal Lipectomy
    Augmentation Mammoplasty
    Cleft Lip/Palate Repair
    Facelift
    Liposuction
    Otoplasty
    Rhinoplasty
    Reduction of Facial Fracture
    Scar Revision
    Skin Meshing
    Split Thickness Skin Grafting
    EYE-FIRST ASSIST WITH FOLLOWING
    Excision of Chalazion
    Canthotomy
    Correction of Ectropian/Entropian
    Corneal Transplant
    Enucleation
    I.O.I. Implants
    Lacrimal Duct Probing
    Refractive Keratoplasty
    Repair of Retinal Detachment
    Vitrectomy
    EAR, NOSE & THROAT-FIRST ASSIST WITH FOLLOWING
    Caldwell-Luc
    Ethymoidectomy
    Frontal Flap Sinus Procedure
    Laryngectomy
    Open Reduction Facial Fractures
    Radical Neck
    Tonsillectomy & Adenoidectomy
    Myringotomy
    Mastoidectomy
    Tympanoplasty
    Stapedectomy
    Nasal Polypectomy
    Laryngoscopy
    THORACIC-FIRST ASSIST WITH FOLLOWING
    Hiatal Hernia
    Pneumonectomy/Lobectomy
    Esophagogastrectomy
    Thoracotomy
    Endoscopic Thoracic Procedures
    Lung/Wedge Resection
    ENDOSCOPY-FIRST ASSIST WITH FOLLOWING
    Bronchoscopy
    Upper Endoscopy (EGD)
    Cystoscopy
    Gastroscopy
    Colonoscopy
    CARDIOVASCULAR-FIRST ASSIST WITH FOLLOWING
    A-V Shunts
    Aortic Aneurysm, Abdominal
    Aorto-Femoral-Pop Bypass Graft
    Cardiac Valve Replacement
    Coronary Artery Bypass Graft-on pump
    Coronary Artery Bypass Graft-off pump
    Endarterectomy-Carotid/Femoral
    Femoral-Popliteal Bypass
    Permanent Pacemaker Implant
    Intra-Aortic Balloon Pump Catheter
    Patent Ductus Repair
    Pericardial Windows
    Portasystemic Shunt
    Repair of Septal Defects
    Thrombectomy
    Vena Cava Ligation
    TRANSPLANTS-FIRST ASSIST WITH FOLLOWING
    Pancreas
    Heart
    Lung
    Liver
    Kidney
    Eye
    WOUND CLOSURE-FIRST ASSIST WITH FOLLOWING
    Suturing
    Stapling
    EQUIPMENT -FIRST ASSIST WITH FOLLOWING
    Robotics
    List Type:
    Fracture Tables
    Video Systems
    CUSA
    Cell Saver
    PACS Diagnostics
    Electrocautery
    Drills
    Stapling Devices
    Ventilators
    Cardiac Monitors
    Stapling Devices