Certified Surgical First Assist Skills Checklist

Let’s assess your clinical skills and experience. Fill out this checklist to get one step closer to your next opportunity.

1 = No theory and/or experience
2 = Limited Experience
3 = Experienced/minimal support needed to perform
4 = Proficient

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Age of Patients Cared For
Newborn/Neonate (birth to 30 days)*
- 1
- 2
- 3
- 4
Infant (1 month to 1 year)*
- 1
- 2
- 3
- 4
Toddler (1 year to 3 years)*
- 1
- 2
- 3
- 4
Preschooler (3 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 years to 79 years)*
- 1
- 2
- 3
- 4
Elderly Adults (over 79+ years)*
- 1
- 2
- 3
- 4
Miscellaneous
Adult Respiratory/ Cardiac Arrest*
- 1
- 2
- 3
- 4
Autoclave*
- 1
- 2
- 3
- 4
Automated Med Dispensing Systems*
- 1
- 2
- 3
- 4
List Type:
Care of Scopes & Fiberoptic Equipment*
- 1
- 2
- 3
- 4
Cidex Soap*
- 1
- 2
- 3
- 4
Crash Cart*
- 1
- 2
- 3
- 4
Defibrillator*
- 1
- 2
- 3
- 4
Electronic Documentation*
- 1
- 2
- 3
- 4
List Types:
Hand-off Communication*
- 1
- 2
- 3
- 4
Isolation Precautions*
- 1
- 2
- 3
- 4
Patient Identification*
- 1
- 2
- 3
- 4
Pediatric Respiratory/ Cardiac Arrest*
- 1
- 2
- 3
- 4
Standard Precautions*
- 1
- 2
- 3
- 4
Universal Protocol*
- 1
- 2
- 3
- 4
General Surgery
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 Procedures
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
Gynecology
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- Oopherectomy*
- 1
- 2
- 3
- 4
Shirodkar Procedure*
- 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. and CYSTO
Circumcision*
- 1
- 2
- 3
- 4
Cystoscopy/ Cystostomy*
- 1
- 2
- 3
- 4
Cystectomy*
- 1
- 2
- 3
- 4
Hypospadius 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
Ureteroscopy*
- 1
- 2
- 3
- 4
T.U.R.P./T.U.R.B*
- 1
- 2
- 3
- 4
Vasectomy*
- 1
- 2
- 3
- 4
Orthopedic
Amputation- Leg/ 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
Neurosurgery
Anterior Cervical Fusion*
- 1
- 2
- 3
- 4
AV Malformation*
- 1
- 2
- 3
- 4
Burrholes for Subdural Hematoma*
- 1
- 2
- 3
- 4
Craniotomy*
- 1
- 2
- 3
- 4
Discectomy/ Laminectomy*
- 1
- 2
- 3
- 4
Laminectomy*
- 1
- 2
- 3
- 4
Meningocele Repair*
- 1
- 2
- 3
- 4
Nerve Stimulators*
- 1
- 2
- 3
- 4
Shunt Procedures- VP/ VA*
- 1
- 2
- 3
- 4
Spinal Procedures/ Fusions*
- 1
- 2
- 3
- 4
Plastics
Abdominoplasty/Abdominal Lipectomy*
- 1
- 2
- 3
- 4
Augmentation Mammoplasty*
- 1
- 2
- 3
- 4
Breast Reduction/ Reconstruction*
- 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
Face Lift*
- 1
- 2
- 3
- 4
Liposuction*
- 1
- 2
- 3
- 4
Otoplasty*
- 1
- 2
- 3
- 4
Rhinoplasty*
- 1
- 2
- 3
- 4
Reduction of Facial Fracture*
- 1
- 2
- 3
- 4
Scar Revisions*
- 1
- 2
- 3
- 4
Skin Grafting*
- 1
- 2
- 3
- 4
Eye
Excision of Chalazion*
- 1
- 2
- 3
- 4
Canthotomy*
- 1
- 2
- 3
- 4
Correction of Ectropian/ Entropian*
- 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 & Throat
Caldwell-Luc*
- 1
- 2
- 3
- 4
Ethmoidectomy*
- 1
- 2
- 3
- 4
Frontal Flap Sinus Procedure*
- 1
- 2
- 3
- 4
Laryngectomy*
- 1
- 2
- 3
- 4
Radical Neck*
- 1
- 2
- 3
- 4
Septoplasty*
- 1
- 2
- 3
- 4
Sinusotomy*
- 1
- 2
- 3
- 4
Tonsillectomy & Adenoidectomy*
- 1
- 2
- 3
- 4
Tracheostomy*
- 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
Endoscopy
Bronchoscopy*
- 1
- 2
- 3
- 4
Cardiothoracic
Chest Tube Set- Up*
- 1
- 2
- 3
- 4
Pneumonectomy/ Lobectomy*
- 1
- 2
- 3
- 4
Septal Defect Repair*
- 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
Vein Harvesting*
- 1
- 2
- 3
- 4
A-V Shunts*
- 1
- 2
- 3
- 4
Aortic Aneurysm, Abdominal*
- 1
- 2
- 3
- 4
Aortofemoral 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
Portasystemic Shunt*
- 1
- 2
- 3
- 4
Repair of Septal Defects*
- 1
- 2
- 3
- 4
Thrombectomy*
- 1
- 2
- 3
- 4
Vena Cava Ligation*
- 1
- 2
- 3
- 4
Transplants
Bone Marrow*
- 1
- 2
- 3
- 4
Pancreas*
- 1
- 2
- 3
- 4
Heart*
- 1
- 2
- 3
- 4
Lung*
- 1
- 2
- 3
- 4
Liver*
- 1
- 2
- 3
- 4
Multhorgan*
- 1
- 2
- 3
- 4
Kidney*
- 1
- 2
- 3
- 4
Eye*
- 1
- 2
- 3
- 4
Trauma
Burns*
- 1
- 2
- 3
- 4
MVA*
- 1
- 2
- 3
- 4
Gun Shot Wounds*
- 1
- 2
- 3
- 4
Stab Wounds*
- 1
- 2
- 3
- 4
Equipment
Robotics*
- 1
- 2
- 3
- 4
List Type:
Fracture Tables*
- 1
- 2
- 3
- 4
List Type:
Video Systems*
- 1
- 2
- 3
- 4
List Type:
CUSA*
- 1
- 2
- 3
- 4
Cell Saver*
- 1
- 2
- 3
- 4
PACS Diagnostics*
- 1
- 2
- 3
- 4
Electrocautery*
- 1
- 2
- 3
- 4
List Type:
Drills*
- 1
- 2
- 3
- 4
List Type:
Saws*
- 1
- 2
- 3
- 4
List Type:
Stapling Devices*
- 1
- 2
- 3
- 4
List Type:
Cardiac Monitors*
- 1
- 2
- 3
- 4
List Type:
Position Patient Per Surgeon's Order*
- 1
- 2
- 3
- 4
Pressure Point Paddling*
- 1
- 2
- 3
- 4
Apply Tourniquet as Ordered*
- 1
- 2
- 3
- 4
Protect From Nerve damage*
- 1
- 2
- 3
- 4
Thermoregulation*
- 1
- 2
- 3
- 4
Use of fracture table*
- 1
- 2
- 3
- 4
Use of head stabilizer*
- 1
- 2
- 3
- 4
Use of body stabilizer*
- 1
- 2
- 3
- 4
Use of c-arm extensions*
- 1
- 2
- 3
- 4
Skin Assessment*
- 1
- 2
- 3
- 4
Use of retractors*
- 1
- 2
- 3
- 4
Packing with sponges*
- 1
- 2
- 3
- 4
Digital Manipulation of tissue*
- 1
- 2
- 3
- 4
Suctioning, Irrigation, Sponging*
- 1
- 2
- 3
- 4
Manipulation of Surgical Materials (Loops, tags)*
- 1
- 2
- 3
- 4
Clamping/Cauterizing vessels or tissues*
- 1
- 2
- 3
- 4
Tying/ligating clamped vessels or tissues*
- 1
- 2
- 3
- 4
Apply hemostatic clips*
- 1
- 2
- 3
- 4
Place Local Hemostatic Agents*
- 1
- 2
- 3
- 4
Direct Digital Pressure*
- 1
- 2
- 3
- 4
Assist in Volume Replacement*
- 1
- 2
- 3
- 4
Assist in Autotransfusion*
- 1
- 2
- 3
- 4
Suturing: all wound layers including muscle & fascia*
- 1
- 2
- 3
- 4
Wound dressing: liquid or spray occlusive*
- 1
- 2
- 3
- 4
Absorbent immobilizing dressing*
- 1
- 2
- 3
- 4
Assist to secure drainage system to tissue*
- 1
- 2
- 3
- 4
Insert/Remove Foley*
- 1
- 2
- 3
- 4
Drape Patient*
- 1
- 2
- 3
- 4
Electrocautery Mono*
- 1
- 2
- 3
- 4
Electrocautery Bipolar*
- 1
- 2
- 3
- 4
Cut Tissue*
- 1
- 2
- 3
- 4
Harvest saphenous vein, including skin incision*
- 1
- 2
- 3
- 4
Dissect Common Femoral Atery and Bifurcate*
- 1
- 2
- 3
- 4
Insert drainage tubes*
- 1
- 2
- 3
- 4
Application Agreement
*
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

Title

Title

Certified Surgical First Assist Skills Checklist

Age of Patients Cared For

Miscellaneous

General Surgery

Laparoscopic Procedures

Gynecology

G.U. and CYSTO

Orthopedic

Neurosurgery

Plastics

Eye

Ear, Nose & Throat

Endoscopy

Cardiothoracic

Transplants

Trauma

Equipment

Application Agreement