Occupational Health Skill Checklist

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.

TRAUMA


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Care of Patient with Minor Trauma
Care of Patient with Major Trauma

Care of Patient with M.A.S.T. Suit

BURNS


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Care of Patient with First Degree
Care of Patient with Second Degree

Care of Patient with Third Degree

Care of Patient with Electrocution

Care of Patient with Hazardous Material Exposure

LACERATIONS


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Care of Patient with Assessment
Care of Patient with Cleansing

Care of Patient with Steri-Strips

Care of Patient with Dressing

SPRAIN/STRAIN


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Assessment
Carpal Tunnel

Tendonitis

Epicondylitis

PHYSICAL


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Safety
Return to work

Respirator

Vital Signs

Height/Weight

Blood Draw

Medical Referral Form

Medical certification Form

Medical History Questionnaire

Potassium Iodide Assessment

RESTRICTIONS


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Temporary Restrictions
Permanent Restrictions

Pulmonary Function

Audiometry

Vision Testing

X-Ray

Urine Testing

Drug Testing

Breath Analyzer

IMMUNIZATIONS


	Never Performed	Limited Experience	Comfortable Performing	Proficient
Havrix (Hepatitis A)
Influenza Vaccine

Meningitis Vaccine

Tetanus & Diphtheria

Oral Typhoid Vaccine

Polio Vaccine

Hepatitis B Vaccine

Japanese Encephalitis B

Typhim (injectable type)

Yellow Fever Vaccine

Statin Medications

Do you speak any languages other than
English?

Yes

No

If yes, which language(s)?

Age Specific Skills

Check the box under EACH age group that you have experience with and are comfortable with for each skill below.

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the different communication needs for the age group & changes communication methods and terminology accordingly

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the different medications, dosages and possible side effects for the age group and administers medications appropriately

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the different safety risks for the age group and alters the environment accordingly

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

Understands the normal growth and development for the age group and adapts care accordingly

Neonates(0-30 days)

Infants(1 mo-1 yr)

Toddlers(1-3 yrs)

Preschool(4-6 yrs)

School Age(7-12 yrs)

Adolescent(13-18 yrs)

Young Adult(19-39 yrs)

Middle Adults(40-64 yrs)

Older Adults(65+ yrs)

*

I hereby certify that ALL information I have provided to Clover Health Services, on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.