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)
    GENERAL SKILLS
    Patient Head to Toe Assessment
    Pain Management
    Automated Med Dispensing Systems
    Care Planning & Discharge Planning
    Patient/Family Education
    Electronic Documentation
    Systems Used - Please List
    Knowledge of Normal Serum Lab Values
    Obtaining Cultures (Blood, Sputum, Swab)
    Administration of Blood & Blood Products
    Interpersonal Communication Skills
    EXPERIENCE IN RESEARCH
    Acute Care Setting
    Clinic Setting
    Long Term Care Setting
    Urban Home Setting
    EXPERIENCED WITH:
    Research Process
    Evidence-Based Nursing
    Institutional Regulatory Board policies
    Coordination of Study Treatments
    Data Collection
    Quantitative Studies
    Data Analysis
    Presentation of Research Study
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