This checklist was electronically signed on (Today’s date)
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
Proficiency Scale:
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Safety Procedures: Protective Attire
Safety Procedures: Standard Precautions
Safety Procedures: Managing Biohazard Waste
Safety Procedures: Sharps Handling
Decontamination: Manual Cleaning
Decontamination: Sharps
Decontamination: Soiled Linens
Decontamination: Use of Washer Sterilizer
Decontamination: Washer Disinfectors
Decontamination: Disinfectants
Decontamination: Cleaning Equipment
Decontamination: Disposable Items
Decontamination: Dress Code
Steam Sterilization: Charting
Steam Sterilization: Cart Loading
Steam Sterilization: Timing
Steam Sterilization: Testing, Monitoring, and Validation
Steam Sterilization: Biological Monitoring
Steam Sterilization: Trouble Shooting
Assembly and Preparation
Assembly and Preparation: Wrapping Procedure
Assembly and Preparation: Instrument set assembly
Assembly and Preparation: Autoclave Tape
Assembly and Preparation: Proper Labeling
Assembly and Preparation: Expiration Dates
Assembly and Preparation: Assembly of Peel Packs
Assembly and Preparation: Assemble hard Instrument Containers
Assembly and Preparation: Proper Towel and Linen Folding
Assembly and Preparation: Dust Covers
Assembly and Preparation: Instrument Count Sheets
Assembly and Preparation: Packing for Steam
Assembly and Preparation: Peel Pack / Heat Sealing
Assembly and Preparation: Instruments on Trays
Assembly and Preparation: Sterile Storage Standards
Equipment Preparation (Area Specific): General
Equipment Preparation (Area Specific): OB/GYN
Equipment Preparation (Area Specific): Neurology
Equipment Preparation (Area Specific): Urology
Equipment Preparation (Area Specific): Cardiac
Equipment Preparation (Area Specific): Laparoscopic
Equipment Preparation (Area Specific): Endoscopic
Equipment Preparation (Area Specific): Robotics
Equipment Preparation (Area Specific): Orthopedics
Equipment Preparation (Area Specific): Ophthalmology
Equipment Preparation (Area Specific): Plastics
Processing: Single Instruments
Processing: Sets and Trays
Processing: Care of Instruments
Processing: Repairs
Processing: Endoscopes
Hospital Experience
Teaching / Educational Setting
Clinic Experience
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)
