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)
  • SCRUB 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:
    Peripheral IV Insertion, Care and Maintenance
    IV Pumps
    Other IV Pumps:
    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?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    GENERAL SURGERY
    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
    Cholecystectomy
    Appendectomy
    Hysterectomy
    Hernia Repair
    Colon Resection
    GYNECOLOGY
    Cesarean Section
    Dilation & Curettage
    Hysterectomy-Vaginal
    Hysterectomy-Abdominal
    Laser Surgery
    Salpingo-Oopherectomy
    Tubal Ligation
    Vaginectomy
    Vaginal Reconstruction
    G.U. AND CYSTO
    Circumcision
    Cystoscopy/Cystostomy
    Cystectomy
    Hypospadius Repair
    Lithotripsy
    Nephrectomy
    Orchiectomy
    Penile Implant
    Prostatectomy
    Ureterolithotomy
    T.U.R.P./T.U.R.B.
    Vasectomy
    ORTHOPEDIC
    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
    Anterior Cervical Fusion
    Burrholes for Subdural Hematoma
    Craniotomy
    Laminectomy
    Shunt Procedures-VP/VA
    PLASTICS
    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
    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
    Caldwell-Luc
    Ethymoidectomy
    Frontal Flap Sinus Procedure
    Laryngectomy
    Open Reduction Facial Fractures
    Radical Neck
    Tonsillectomy & Adenoidectomy
    Myringotomy
    Mastoidectomy
    Tympanoplasty
    Stapedectomy
    Nasal Polypectomy
    Laryngoscopy
    THORACIC
    Hiatal Hernia
    Pneumonectomy/Lobectomy
    Esophagogastrectomy
    Thoracotomy
    Endoscopic Thoracic Procedures
    Lung/Wedge Resection
    ENDOSCOPY
    Bronchoscopy
    Upper Endoscopy (EGD)
    Cystoscopy
    Gastroscopy
    Colonoscopy
    CARDIOVASCULAR
    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 Insertion
    Intra-Aortic Balloon Pump Catheter
    Patent Ductus Repair
    Pericardial Windows
    Portasystemic Shunt
    Repair of Septal Defects
    Thrombectomy
    Vena Cava Ligation
    TRANSPLANTS
    Pancreas
    Heart
    Lung
    Liver
    Kidney
    Eye
    EQUIPMENT
    Robotics
    List Type:
    Fracture Tables
    Video Systems
    CUSA
    Cell Saver
    PACS Diagnostics
    Electrocautery
    Drills
    Stapling Devices
    Ventilators
    Cardiac Monitors
    Stapling Devices
    STERILIZATION OF EQUIPMENT
    Log
    Biological Indicators
    Autoclave Operation
    High Level
    STERIS
    Steam
    Gas
    Flash