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.)
    Management of Malignant Hyperthermia
    Time Out Procedure Pre-Op
    Knowledge/Use of Crash Carts
    Knowledge of "Do Not Use Abbreviations"
    Knowledge of OR Fire Safety
    Knowledge of Laser Safety
    Do you have charge/supervisor experience?
    GENERAL SURGERY-FIRST ASSIST WITH FOLLOWING
    Appendectomy
    Abdominal Perineal Resection
    Bowel Resection
    Breast Surgeries-Radical Mastectomy, Lumpectomy
    Cholecystectomy
    Gastrectomy
    Herniorrhaphy-Femoral/Inguinal, ventral, umbilical
    Hiatal Herniorrhaphy-Transabdominal
    Laparoscopic General Surgeries
    Organ Procurement
    Radical Mastectomy
    Breast biopsy
    Gastric Bypass
    Splenectomy
    Thyroidectomy
    Tracheostomy
    Whipple
    ROBOTICS
    Bariatrics
    Cardiothoracic
    Colorectal
    ENT
    General
    GYN
    Ortho
    Urology
    GYNECOLOGY-FIRST ASSIST WITH FOLLOWING
    Cesarean Section
    Dilation & Curettage
    Hysterectomy-Vaginal
    Hysterectomy-Abdominal
    Laser Surgery
    Laparoscopic Gynecology Surgeries
    Salpingo-Oopherectomy
    Tubal Ligation
    Vaginectomy
    Vaginal Reconstruction
    G.U. AND CYSTO-FIRST ASSIST WITH FOLLOWING
    Circumcision
    Cystoscopy/Cystostomy
    Cystectomy
    Hypospadius Repair
    Laparoscopic G.U. Surgeries
    Lithotripsy
    Nephrectomy
    Orchiectomy
    Penile Implant
    Prostatectomy
    Ureterolithotomy
    T.U.R.P./T.U.R.B.
    Vasectomy
    ORTHOPEDIC-FIRST ASSIST WITH FOLLOWING
    Amputation
    Anterior Cruciate Ligament Reconstruction
    Arthroscopy/Arthrotomy
    Closed Pinning & Reduction of Extremities
    External Fixation Devices
    Hand Surgeries
    Total Joint Replacement - Knee, Hip, Shoulder
    Spinal Fusion-Harrington Rods
    O.R.I.F.-Shoulder, Hip, Humerus etc.
    Patellectomy
    Podiatry
    Tendon Implants & Reanastomosis
    NEUROSURGERY-FIRST ASSIST WITH FOLLOWING
    Anterior Cervical Fusion
    Burrholes for Subdural Hematoma
    Craniotomy
    Laminectomy
    Navigation Guided Procedures
    Transforaminal Lumbar Interbody Fusion (TLIF)
    Transsphenoidal
    Shunt Procedures-VP/VA
    PLASTICS-FIRST ASSIST WITH FOLLOWING
    Abdominoplasty/Abdominal Lipectomy
    Augmentation Mammoplasty
    Breast Reconstruction
    Burns
    Cleft Lip/Palate Repair
    Facelift
    Facial Reconstruction
    Gender Reassignment
    Liposuction
    Microvascular
    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
    IOL Implants
    Lacrimal Duct Probing
    Refractive Keratoplasty
    Repair of Retinal Detachment
    Scleral Buckle
    Vitrectomy
    EAR, NOSE & THROAT-FIRST ASSIST WITH FOLLOWING
    Caldwell-Luc
    Cochlear Implant
    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
    Esophagectomy
    Esophagogastrectomy
    Thoracotomy
    Endoscopic Thoracic Procedures
    Lung/Wedge Resection
    ENDOSCOPY-FIRST ASSIST WITH FOLLOWING
    Bronchoscopy
    Upper Endoscopy (EGD)
    Cystoscopy
    ERCP
    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
    Electrocautery (ESU)
    Laparoscopy Systems
    Neuro
    Fracture Tables
    Split Leg Tables
    Ortho Total Joints Systems
    Power Equipment
    Spinal Fusion Instrumentation
    Tourniquet Matching & Test Gauge
    Stapling Devices