Age of Patients Cared ForNewborn/Neonate (Birth to 30 days)* 1 2 3 4 Infant (1 month to 1 year)* 1 2 3 4 Preschooler (3 year to 5 years)* 1 2 3 4 Toddler (1 year to 3 years)* 1 2 3 4 Preschooler (years to 5 years)* 1 2 3 4 School Age Child (5 years to 12 years)* 1 2 3 4 Adolescents (12 years to 18 years)* 1 2 3 4 Young Adults (18 years to 39 years)* 1 2 3 4 Middle Adults (39 years to 64 years)* 1 2 3 4 Older Adults (64 to 79 years)* 1 2 3 4 Elderly Adults (over 79+ years)* 1 2 3 4 General SurgeryScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Abdominal Perineal Resection* 1 2 3 4 Adrenalectomy* 1 2 3 4 Bowel Resection* 1 2 3 4 Cholecystectomy* 1 2 3 4 Colostomy/Ileostomy* 1 2 3 4 Gastrectomy* 1 2 3 4 Hemicolectomy* 1 2 3 4 Hepatic Resection* 1 2 3 4 Herniorrhaphy-Femoral/Inguinal* 1 2 3 4 Hiatal Herniorrhaphy-Transabdominal* 1 2 3 4 Pancreatectomy* 1 2 3 4 Organ Procurement* 1 2 3 4 Radical Mastectomy* 1 2 3 4 Saphenous Vein Ligation and Stripping* 1 2 3 4 Splenectomy* 1 2 3 4 Thyroidectomy* 1 2 3 4 Tracheostomy* 1 2 3 4 Whipple Procedure* 1 2 3 4 Laparoscopic ProceduresScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Hysterectomy* 1 2 3 4 Cholecystectomy* 1 2 3 4 Appendectomy* 1 2 3 4 Hernia Repair* 1 2 3 4 Colon Resection* 1 2 3 4 GynecologyScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Caesarean Section* 1 2 3 4 Dilation & Curettage* 1 2 3 4 Hysterectomy-Vaginal* 1 2 3 4 Hysterectomy-Abdominal* 1 2 3 4 Laser Surgery* 1 2 3 4 Radium Insertion* 1 2 3 4 Salpingo-Opherectomy* 1 2 3 4 Shirodkar Procedures* 1 2 3 4 Termination of Pregnancy* 1 2 3 4 Tubal Ligation* 1 2 3 4 Vaginectomy* 1 2 3 4 Vaginal Reconstruction* 1 2 3 4 G.U. & CystoScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Circumcision* 1 2 3 4 Cystoscopy/Cystostomy* 1 2 3 4 Cystectomy* 1 2 3 4 Hypospadias Repair* 1 2 3 4 Ileal Loop* 1 2 3 4 Lithotripsy* 1 2 3 4 Nephrectomy* 1 2 3 4 Orchiectomy* 1 2 3 4 Penile Implant* 1 2 3 4 Prostatectomy* 1 2 3 4 Ureterolithotomy* 1 2 3 4 T.U.R.P./T.U.R.B.* 1 2 3 4 Vasectomy* 1 2 3 4 OrthopedicAmputation - Led or Arm* 1 2 3 4 Application of Halo Traction* 1 2 3 4 Arthroscopy/Arthrotomy* 1 2 3 4 Closed Pinning & Reduction of Extremities* 1 2 3 4 External Compression Devices* 1 2 3 4 Insertion of Finger Prosthesis* 1 2 3 4 Total Joint Replacement - Knee, Hip, Shoulder* 1 2 3 4 Spinal Fusion - Harrington Rods* 1 2 3 4 Spica Cast Application* 1 2 3 4 O.R.I.F. - Shoulder, Hip, Humerus, Etc.* 1 2 3 4 Repair of Dislocation* 1 2 3 4 Patellectomy* 1 2 3 4 Tendon Implants & Reanastomosis* 1 2 3 4 NeurosurgeryScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Anterior Cervical Fusion* 1 2 3 4 Burrholes for Subdural Hematoma* 1 2 3 4 Craniotomy* 1 2 3 4 Laminectomy* 1 2 3 4 Meningocele Repair* 1 2 3 4 Shunt Procedures - VP/VA* 1 2 3 4 PlasticsScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Face Lift* 1 2 3 4 Skin Grafting* 1 2 3 4 Abdominoplasty/Abdominal Lipectomy* 1 2 3 4 Augmentation Mammoplasty* 1 2 3 4 Cleft Lip/Palate Repair* 1 2 3 4 Dermabrasion* 1 2 3 4 Digital Flexor Tendon Repair* 1 2 3 4 Liposuction* 1 2 3 4 Myelomeningocele Repair* 1 2 3 4 Otoplasty* 1 2 3 4 Rhinoplasty* 1 2 3 4 Reduction of Facial Fracture* 1 2 3 4 EyeScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Excision of Chalazion* 1 2 3 4 Canthotomy* 1 2 3 4 Correction of Ectropion/Entropion* 1 2 3 4 Corneal Transplant* 1 2 3 4 Enucleation* 1 2 3 4 I.O.I. Implants* 1 2 3 4 Lacrimal Duct Probing* 1 2 3 4 Refractive Keratoplasty* 1 2 3 4 Repair of Retinal Detachment* 1 2 3 4 Vitrectomy* 1 2 3 4 Ear, Nose & ThroatScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Caldwell-Luc* 1 2 3 4 Ethmoidectomy* 1 2 3 4 Frontal Flap Sinus Procedure* 1 2 3 4 Laryngectomy* 1 2 3 4 Open Reduction Facial Fractures* 1 2 3 4 Radical Neck* 1 2 3 4 Tonsillectomy & Adenoidectomy* 1 2 3 4 Myringotomy* 1 2 3 4 Mastoidectomy* 1 2 3 4 Tympanoplasty* 1 2 3 4 Stapedectomy* 1 2 3 4 Nasal Polypectomy* 1 2 3 4 Laryngoscopy* 1 2 3 4 ThoracicScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Chest Tube Set-Up* 1 2 3 4 Hiatal Hernia* 1 2 3 4 Pneumonectomy/ Lobectomy* 1 2 3 4 Sternal Splitting* 1 2 3 4 Thoracotomy* 1 2 3 4 Bronchoscopy* 1 2 3 4 Lung/Wedge Resection* 1 2 3 4 EndoscopyScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Bronchoscopy* 1 2 3 4 Cystoscopy* 1 2 3 4 Gastroscopy* 1 2 3 4 Colonoscopy* 1 2 3 4 CardiovascularScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 A-V Shunts* 1 2 3 4 Aortic Aneurysm, Abdominal* 1 2 3 4 Aorto-Femoral Bypass* 1 2 3 4 Graft Insertion* 1 2 3 4 Cardiac Valve Replacement* 1 2 3 4 Coronary Artery Bypass Graft-on Pump* 1 2 3 4 Endarterectomy, Carotid/Femoral* 1 2 3 4 Femoral-Popliteal Bypass* 1 2 3 4 External Temporary Pacemaker* 1 2 3 4 Internal Pacemaker Insertion* 1 2 3 4 Intra-Aortic Balloon Pump Catheter* 1 2 3 4 Patent Ductus Repair* 1 2 3 4 Pericardial Windows* 1 2 3 4 Repair of Septal Defects* 1 2 3 4 Thrombectomy* 1 2 3 4 Vena Cava Ligation* 1 2 3 4 TransplantsScrub* 1 2 3 4 Circulate* 1 2 3 4 First Assist* 1 2 3 4 Pancreas* 1 2 3 4 Heart* 1 2 3 4 Lung* 1 2 3 4 Liver* 1 2 3 4 Kidney* 1 2 3 4 Eye* 1 2 3 4 EquipmentRobotics* 1 2 3 4 List Types:Fracture Tables* 1 2 3 4 List Types:Video Systems* 1 2 3 4 List Types:CUSA* 1 2 3 4 Cell Saver* 1 2 3 4 PACS Diagnostics* 1 2 3 4 Electrocautery* 1 2 3 4 List Types:Drills* 1 2 3 4 List Types:Saws* 1 2 3 4 List Types:Stapling Devices* 1 2 3 4 Cardiac Monitors* 1 2 3 4 List Types:Crash Carts* 1 2 3 4 List Types:Defibulators* 1 2 3 4 List Types:Sterilization of EquipmentLog* 1 2 3 4 Biological Indicators* 1 2 3 4 Autoclave Operations* 1 2 3 4 High Level* 1 2 3 4 STERIS* 1 2 3 4 Steam* 1 2 3 4 Gas* 1 2 3 4 Flash* 1 2 3 4 MiscellaneousUniversal Protocol* 1 2 3 4 Crash Cart* 1 2 3 4 Patient Identification* 1 2 3 4 Hand-Off Communication* 1 2 3 4 Standard Precautions* 1 2 3 4 Isolation Precautions* 1 2 3 4 Pediatric Respiratory/Cardiac Arrest* 1 2 3 4 Automated Med Dispensing Systems* 1 2 3 4 List Types:Please list the EMR systems you have used** I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form.** I hereby consent to allow CrossMed Healthcare Staffing Solutions to release these skills checklist to the client facilities.*Name* First Last Email* Phone*TODAY'S DATE* MM slash DD slash YYYY
