The following checklist is a profile used to assess your Operating Room proficiency and assist in matching your skills with available assignments. Your employment is not dependent upon responses given on this checklist. Please rate your ability as accurately as possible by checking the appropriate option. Step 1 of 5 20% Name* First Middle Last PLEASE MARK YOUR LEVEL OF EXPERIENCE 0 - No Experience 1 - Theory/Observed Only 2 - Intermittent Experience 3 - Moderate Experience 4 – Expert General SkillsCardiac Arrest/ Adult CPR01234Cardiac Arrest/ Infant-Child CPR01234Care of patient in restraints01234Universal Precautions01234Care of the patient in isolation01234Organ Donor Protocols01234Lift/ Transfer Devices01234Electronic Documentation01234General SurgeryAbdominal Perineal Resection01234Adrenalectomy01234Bariatric Surgery (gastric bypass)01234Bowel Resection01234Cholecystectomy/Cholangiogram01234Colostomy/Ileostomy01234Gastrectomy01234Hemicolectomy01234Hepatic Resection01234Herniorraphy-Femoral/Inguinal01234Hiatal Herniorraphy-Transabdominal01234Pancreatectomy01234Organ Procurement01234Radical Mastectomy01234Saphenous Vein Ligation/Stripping01234Splenectomy01234Thyroidectomy01234Tracheostomy01234Vagotomy01234Familiarity with Pediatric Procedures01234 GynecologyCaesarean Section01234Dilation & Curettage01234Hysterectomy-Vaginal01234Hysterectomy-Abdominal01234Laser Surgery01234Radium Insertion01234Salpingo-Oopherectomy01234Termination of Pregnancy01234Shirodkar Procedure01234Tubal Ligation01234Vaginectomy01234Endoscopic ProceduresBronchoscopy01234Culdoscopy01234Cystoscopy01234Esophagoscopy01234Gastroscopy01234Hysteroscopy01234Laparoscopic ProceduresAppendectomy01234Cholecystectomy01234Colon Resection01234Hernia Repair01234Salpingo-Oophorectomy01234Tubal Ligation01234Vaginal Hysterectomy01234Laryngoscopy01234Mediastinoscopy01234Pelviscopy01234Sigmoidscopy01234Thoracoscopy01234Whipple01234Nissen Fundalplication01234Other (Please Specify) UrologyCircumcision01234Cystoscopy/Ureteroscopy01234Cystectomy01234Hypospadius Repair01234Implants01234Lithotripsy01234Nephrectomy01234Orchiectomy01234Prostatectomy01234Ureterolithotomy01234TURP01234PVP-photo vaporization of prostate01234Vasectomy01234OrthopedicAchilles Tendon Repair01234Amputation01234Arthroscopy/Arthrotomy01234Closed Pinning & Reduction of Extremities01234External Compression Devices01234Hip compression nails and lag screws01234Total Joint Replacement-knee, hip, shoulder01234Spica Cast01234ORIF-shoulder, hip, humerus01234Repair of Dislocation01234Patellectomy01234Tendon Implants and Reanastomosis01234Antegrade/Retrograde Roddings01234Humoral Fracture01234Tibial Fracture01234Femoral Fracture01234NeurologyKyphoplasty01234A-V malformation01234Laparoscopic spine procedures01234Burr Holes for Subdural Hematoma01234Cartoid ligation01234Cervical Sympathectomy01234Cranioplasty01234Craniotomy01234Disectomy/laminectomy01234Halo Traction application01234Insertion of nerve stimulus device01234Myelomeningocele repair01234Shunt Procedure VP/VA/LP01234Spinal Fusions01234Ventriculostomy01234 PlasticsAbdominal lipectomy01234Blepharoplasty01234Face Lift01234Mammoplasty01234Augmentation01234Reduction01234Reconstructive01234Liposuction01234Otoplasty01234Scar Revisions01234Skin Grafting01234OphthalmologyCataract extraction01234IOL Implants01234Corneal transplant01234Orbital implant01234Enucleation01234Repair Orbital Blowout Fracture01234Repair of Retinal Detachment01234Scleral Buckle01234Ear, Nose & ThroatCaldwell-Luc01234Cleft lip/Palate Repair01234Larynegectomy01234Radical Neck01234Tonsillectomy & Adenoidectomy01234Mandibulectomy01234Masteoidectomy01234Rhinoplasty/Septoplasty01234Sinusotomy01234Tracheostomy01234VascularAngiography01234A-V access graft01234Aortic Aneurysm Endarterectomy01234Peripheral Vascular Bypass01234Resection Carotid Aneurysm/Graft01234Thrombectomy01234Embolectomy01234Vena Cava Ligation01234EndovascularEndoluminal AAA01234Other (Specify)01234Thoracic/CardiovascularAortic Femoral Bypass graft01234Femoral Popliteal Bypass01234Pacemaker Implantation/Explanation01234Care of patients with pacemaker01234Cardiac Cath Lab-IABP01234Septal Defects, ASV, VSD01234Coronary Artery Bypass Graft01234Maze Procedure01234Valve Replacement01234Aortic Aneurysm01234Thoacotomy01234Lobectomy01234Rib Resection01234Endoscopic Vein Harvesting01234Off Pump Bypass01234TransplantBone01234Cornea01234Harvesting01234Heart/Lung01234Kidney01234Liver01234Multi Organ01234Pancreas01234Skin01234TraumaBurns01234Gunshot/ Stab wounds01234Motor Vehicle Accidents01234Traumatic amputations01234Open Fractures01234Hematoma: Subdural/Epidural01234 EquipmentTransfer/Lift Devices01234Computerized Documentation01234Medication Pumps01234Abinmed Machine01234Camera/Video Systems01234Cell Saver01234Cidex Soak01234Crypo-ophthalmic unit01234CUSA01234Hypo/Hyperthermia Unit01234Drills and Saws01234Electrosurgical unit01234Fiber optic laminator01234Cavitron01234Autoclave01234Fracture Tables01234Stapling Devices01234Mesh Graft/Dermatone01234Microscopes01234Nitrogen Tank01234Pneumatic tourniquet01234Steris Unit01234Pulsevac Irrigation01234Autotransfusion Device01234Laser Equipment01234Care of Scopes and Fiberoptic Equipment01234Venodyne01234Age Specific - Patients Cared ForInfants and Toddlers (ages 0-3 years)01234Young Children (ages 4-6 years)01234Older Children (ages 7-12 years)01234Adolescent Children (ages 13-20 years)01234Young Adults (ages 21-39 years)01234Middle Adults (ages 40-64 years)01234Older Adults (ages 65-79 years)01234Elderly Ages (ages >80 years)01234Additional SkillsSkillsTrainingEquipmentAcceptanceThe information I have given is true and accurate to the best of my knowledge. In addition, I hereby authorize Fidelis Partners to release this Operating Room Profile to client institutions of Fidelis Partners in consideration of my employment with that institution.SignatureUse your finger (if on a mobile device) or cursor to draw your signature.
