Skills Checklist Nurse Practitioner Self-Assessment "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.First NameThis field is hidden when viewing the formLast NameThis field is hidden when viewing the formEmail* This field is hidden when viewing the formToday's Date* MM slash DD slash YYYY InstructionsTo provide suitable assignments for you, this checklist is intended as a method of assessing your professional proficiency. Please rate your skill level as accurately as possible by placing a check (√) in the appropriate box. LEVEL OF PROFICIENCY: Theory – No Experience = 1 Minimal Experience (0-12 Months) = 2 Experienced/Competent (Greater than 12 Months) = 3 Able to Teach/Supervise = 4 SKILLS - GENERAL HEALTH MAINTENANCEDisease and Disability Prevention 1 2 3 4 Health Screening 1 2 3 4 Health Teaching 1 2 3 4 RESPIRATORY DISORDERSAcute Bronchitis 1 2 3 4 Bronchial Asthma (Adult) 1 2 3 4 Bronchial Asthma (Pediatric) 1 2 3 4 Influenza 1 2 3 4 Pneumonia (Adult) 1 2 3 4 Pneumonia (Pediatric) 1 2 3 4 Pulmonary Tuberculosis 1 2 3 4 SKIN DISORDERSAcne 1 2 3 4 Basal Cell Carcinoma 1 2 3 4 Dermatitis 1 2 3 4 Folliculitis 1 2 3 4 Herpes Simplex 1 2 3 4 Malignant Melanoma 1 2 3 4 Pityriasis Rosea 1 2 3 4 Scabies 1 2 3 4 Shingles 1 2 3 4 Urticaria (Hives) 1 2 3 4 Warts 1 2 3 4 EMERGENCIESAnaphylaxis 1 2 3 4 Animal Bites 1 2 3 4 Cardiac Arrest 1 2 3 4 Convulsions 1 2 3 4 Drug Overdose 1 2 3 4 Minor Burns 1 2 3 4 Minor Head Injuries 1 2 3 4 Open Wounds 1 2 3 4 Shock 1 2 3 4 CARDIOVASCULAR DISEASEAngia Pectoris 1 2 3 4 Congestive Heart Failure 1 2 3 4 Congenital Heart Disease 1 2 3 4 Coronary Artery Disease 1 2 3 4 Pericarditis 1 2 3 4 Uncomplicated Hypertension 1 2 3 4 MENTAL HEALTH DISORDERSAnxiety 1 2 3 4 Depression 1 2 3 4 Eating Disorders 1 2 3 4 Obesity 1 2 3 4 Substance Abuse 1 2 3 4 GASTROINTESTINAL DISORDERSAppendicitis 1 2 3 4 Colic, Pediatric 1 2 3 4 Constipation 1 2 3 4 Diarrhea, Simple 1 2 3 4 Gastroenteritis 1 2 3 4 Hemorrhoids 1 2 3 4 Irritable Bowel Syndrome 1 2 3 4 OTHEREar, Nose and Throat Disorders 1 2 3 4 Endocrine System Disorders 1 2 3 4 Hematalogic System Disorders 1 2 3 4 Infection Diseases 1 2 3 4 Musculoskeletal System Disorders 1 2 3 4 Nervous System Disorder 1 2 3 4 Certification(s)BLS Expiration DateACLS Expiration DateNRP Expiration DatePALS Expiration DateOTHER Expiration DateOTHER Expiration DateLicensure(s)Licensure NumberStateExpiration DateLicensure NumberStateExpiration DateLicensure NumberStateExpiration DateLicensure NumberStateExpiration DateLicensure NumberStateExpiration DateAREAS OF EXPERTISEManagement Duties: Months and YearsCharge Duties: Months and YearsADDITIONAL EXPERTISEPlease list any additional areas of expertise below:Consent I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.
