|
Name: _____________________
|
|
|
|
|
|
|
|
Rev
|
7/26/2007
|
|
|
Please list actual number of years and months experience
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Years/Months
|
|
|
|
|
|
Years/Months
|
|
|
N010101
|
|
Ablation
|
|
|
_______/______
|
|
N010206
|
Instrument Experience
|
_______/______
|
|
|
N010106
|
|
Assessments
|
|
_______/______
|
|
N010210
|
IUD Insertion/Removal
|
|
_______/______
|
|
|
N010108
|
|
Audiology Tests
|
|
_______/______
|
|
N010214
|
Starting IV's
|
|
_______/______
|
|
|
N010116
|
|
Biopsy
|
|
|
_______/______
|
|
N010218
|
LEEP Procedure
|
|
_______/______
|
|
|
|
|
Brochoscopes
|
|
_______/______
|
|
N010222
|
Lipo Surgery
|
|
_______/______
|
|
|
N010126
|
|
Casting
|
|
|
_______/______
|
|
N010226
|
Minor Surgeries
|
|
_______/______
|
|
|
N010128
|
|
Catheterization
|
|
_______/______
|
|
N010230
|
Mole/Wart Removal
|
|
_______/______
|
|
|
N010131
|
|
Chaperone
|
|
_______/______
|
|
N010231
|
Nebulizer Treatments
|
|
_______/______
|
|
|
N01013301
|
Chemotherapy-Hang
|
|
_______/______
|
|
N010233
|
Needle Aspirations
|
|
_______/______
|
|
|
N01013303
|
Chemotherapy-Mix
|
|
_______/______
|
|
N010234
|
Norplant Removals
|
|
_______/______
|
|
|
N01013305
|
Chemotherapy-Administer
|
_______/______
|
|
N010238
|
OSHA
|
|
|
_______/______
|
|
|
N010135
|
|
Circulating
|
|
_______/______
|
|
N010242
|
Pap Smears
|
|
_______/______
|
|
|
N010137
|
|
Circumcision
|
|
_______/______
|
|
N010243
|
Patient Education
|
|
_______/______
|
|
|
N010140
|
|
Colonoscopy
|
|
_______/______
|
|
N010245
|
Peak Flow Meter
|
|
_______/______
|
|
|
N010143
|
|
CPR
|
|
|
_______/______
|
|
N01024603
|
Phlebotomy-Pediatrics
|
_______/______
|
|
|
N010146
|
|
Cryosurgery
|
|
_______/______
|
|
N01024605
|
Phlebotomy-Adolescents
|
_______/______
|
|
|
N010149
|
|
Dialysis
|
|
|
_______/______
|
|
N01024607
|
Phlebotomy-Adults
|
|
_______/______
|
|
|
N010151
|
|
Dressing Changes
|
|
_______/______
|
|
N010250
|
Physical Examinations
|
_______/______
|
|
|
N010153
|
|
EEG
|
|
|
_______/______
|
|
N010254
|
PKU's
|
|
|
_______/______
|
|
|
N01015501
|
EKG-12 lead
|
|
_______/______
|
|
N010256
|
Prescription Refills
|
|
_______/______
|
|
|
N01015503
|
EKG-10 lead
|
|
_______/______
|
|
N010258
|
Pulmonary Function Testing
|
_______/______
|
|
|
N01015505
|
EKG-5 lead
|
|
_______/______
|
|
N010260
|
Pulsoximeter
|
|
_______/______
|
|
|
N010160
|
|
Endometrial Biopsies
|
_______/______
|
|
N010266
|
Rectal Exams
|
|
_______/______
|
|
|
N010164
|
|
Flexsigmoidoscopies
|
_______/______
|
|
N010268
|
Sleep Apnea
|
|
_______/______
|
|
|
N010168
|
|
Fingersticks
|
|
_______/______
|
|
N010269
|
Treadmill/Stress Tests
|
_______/______
|
|
|
N010176
|
|
HB Vaccines
|
|
_______/______
|
|
N010270
|
Spirometry
|
|
|
_______/______
|
|
|
N010186
|
|
Heel Sticks
|
|
_______/______
|
|
N010271
|
Suture Removal
|
|
_______/______
|
|
|
N010192
|
|
History Taking
|
|
_______/______
|
|
N010274
|
Toenail Removal
|
|
_______/______
|
|
|
N010196
|
|
Holter Monitor
|
|
_______/______
|
|
N010278
|
Trach Experience
|
|
_______/______
|
|
|
N01020203
|
Injections-Pediatrics
|
|
_______/______
|
|
N01028101
|
Triage-Phone
|
|
_______/______
|
|
|
N01020205
|
Injections-Adolescents
|
_______/______
|
|
N010282
|
Triage-Walk-in
|
|
_______/______
|
|
|
N01020207
|
Injections-Adults
|
|
_______/______
|
|
N01028204
|
Triage-On Computer
|
|
_______/______
|
|
|
N01020209
|
Injections-Intramuscular
|
_______/______
|
|
N010294
|
Ventilators
|
|
|
_______/_____
|
|
|
N01020211
|
Injections-Subcutaneous
|
_______/______
|
|
N010296
|
Vasectomies
|
|
_______/______
|
|
|
N01020213
|
Injections-Medications
|
_______/______
|
|
N010297
|
Vitals
|
|
|
_______/______
|
|
|
N01020217
|
Injections-Trigger Point
|
_______/______
|
|
C0405
|
Medical Records-Charting
|
_______/______
|
|
|
|
|
|
|
|
|
|
K0327
|
Bilingual-Spanish
|
|
_______/______
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
X-RAY SKILLS:
|
|
|
|
|
|
OPHTHALMOLOGY SKILLS:
|
|
|
|
|
Please list actual number of years experience
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N0902
|
|
X-Ray/Abdomen
|
|
_______/______
|
|
N080101
|
A-Scans
|
|
|
|
_______/______
|
|
N090201
|
|
X-Ray/Back & Spine
|
|
_______/______
|
|
N08010101
|
Topography
|
|
|
_______/______
|
|
N090208
|
|
X-Ray/Chest
|
|
_______/______
|
|
N080111
|
Photo Radial Kerotonomy-PRK
|
_______/______
|
|
N090211
|
|
C-Arm
|
|
|
_______/______
|
|
N080115
|
Retinoscopic
|
|
|
_______/______
|
|
N090210
|
|
X-Ray/Skull
|
|
_______/______
|
|
N080121
|
Frame Styling
|
|
|
_______/______
|
|
N090212
|
|
CT Scan
|
|
|
_______/______
|
|
N080124
|
Lens Dispensing
|
|
|
_______/______
|
|
N090216
|
|
X-Ray/Extremeties
|
|
_______/______
|
|
N080127
|
Lens Fitting
|
|
|
_______/______
|
|
N090218
|
|
Bone Densitometer
|
|
_______/______
|
|
N080130
|
Lensometry
|
|
|
_______/______
|
|
N090220
|
|
Fluoroscopy
|
|
_______/______
|
|
N080133
|
Muscle Balance
|
|
|
_______/______
|
|
N090222
|
|
IVP (Injecting Contrast)
|
_______/______
|
|
N080136
|
Photography-Fundis
|
|
|
_______/______
|
|
N090224
|
|
Mammography
|
|
_______/______
|
|
N080140
|
Fluorescein Angiograms
|
|
_______/______
|
|
N090228
|
|
MRI
|
|
|
_______/______
|
|
N080144
|
Pupil Check
|
|
|
_______/______
|
|
N090230
|
|
Nuclear Medicine
|
|
_______/______
|
|
N080148
|
Refractions
|
|
|
_______/______
|
|
N090232
|
|
X-Ray/Neck
|
|
_______/______
|
|
N080156
|
Scribe
|
|
|
|
_______/______
|
|
N090234
|
|
Radiation Therapy
|
|
_______/______
|
|
N080160
|
Slit Lamp Exam
|
|
|
_______/______
|
|
N090240
|
|
Sonography
|
|
_______/______
|
|
N080164
|
Stabismus
|
|
|
|
_______/______
|
|
N090244
|
|
Ultrasound
|
|
|
|
N080168
|
Surgery Scrub
|
|
|
_______/______
|
|
|
|
|
|
|
|
|
N080172
|
Tonometry
|
|
|
|
_______/______
|
|
LAB SKILLS:
|
|
|
|
|
|
N080176
|
Triachiasis
|
|
|
|
_______/______
|
|
N0701
|
|
ABG/Blood Gases
|
|
_______/______
|
|
N080180
|
Visual Acuity
|
|
|
_______/____
|
|
N0703
|
|
Basic Lab Skills
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0705
|
|
CBC
|
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0707
|
|
Drug Screen Testing
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0709
|
|
Gestational Diabetes
|
_______/______
|
|
|
|
|
|
|
|
|
N0710
|
|
Glucose Testing
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0711
|
|
Hormonal Imbalance
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0712
|
|
Mono Testing
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0713
|
|
Prenatal Profile
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0714
|
|
Pregnancy Testing
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0715
|
|
Prothrombin Time (PT)
|
_______/______
|
|
|
|
|
|
|
|
|
N0717
|
|
Sexually Transmitted Disease
|
_______/______
|
|
|
|
|
|
|
|
|
N0719
|
|
Strep Testing
|
|
_______/______
|
|
|
|
|
|
|
|
|
N0721
|
|
Thyroid Profile
|
|
_______/______
|
|
|
|
|
|
|
|
|
|
