Operating Room Tech Skills Checklist

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

Age of Patients Cared For
Newborn/Neonate (birth to 30 days)*
- 1
- 2
- 3
- 4
Infant (31 days to 12 months)*
- 1
- 2
- 3
- 4
Toddler/Preschool (13 months to 5 years)*
- 1
- 2
- 3
- 4
School Age Child/adolescent (6 years to 18 years)*
- 1
- 2
- 3
- 4
Young Adults/Middle Adult (19 years to 64 years)*
- 1
- 2
- 3
- 4
Older Adults/Elderly (65+ years)*
- 1
- 2
- 3
- 4
GENERAL SKILLS
Knowledge of current Joint Commission National Patient Safety Goals*
- 1
- 2
- 3
- 4
Knowledge/familiarity with HCAHPS scores*
- 1
- 2
- 3
- 4
Knowledge of "Do Not Use Abbreviations"*
- 1
- 2
- 3
- 4
Do you have charge/supervisor experience?*
- Yes
- No
IV Pumps*
- Alaris
- Alibaba
- Bard
- Baxter
- Braun
- CADD
- IVAC
- Zynomed
- N/A
Other IV Pumps:
SCRUB EXPERIENCE WITH THE FOLLOWING
Abdominal Perineal Resection*
- 1
- 2
- 3
- 4
Bowel Resection*
- 1
- 2
- 3
- 4
Cholecystectomy*
- 1
- 2
- 3
- 4
Gastrectomy*
- 1
- 2
- 3
- 4
Herniorrhaphy-Femoral/Inguinal, ventral, umbilical*
- 1
- 2
- 3
- 4
Hiatal Herniorrhaphy-Transabdominal*
- 1
- 2
- 3
- 4
Laparoscopic General Surgeries*
- 1
- 2
- 3
- 4
Organ Procurement*
- 1
- 2
- 3
- 4
Radical Mastectomy*
- 1
- 2
- 3
- 4
Splenectomy*
- 1
- 2
- 3
- 4
Thyroidectomy*
- 1
- 2
- 3
- 4
Tracheostomy*
- 1
- 2
- 3
- 4
LAPAROSCOPIC PROCEDURES
Cholecystectomy*
- 1
- 2
- 3
- 4
Appendectomy*
- 1
- 2
- 3
- 4
Hysterectomy*
- 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
Salpingo-Oopherectomy*
- 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
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
Orthopedic
Anterior Cruciate Ligament Reconstruction*
- 1
- 2
- 3
- 4
Carpal Tunnel surgery*
- 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
Burrholes for Subdural Hematoma*
- 1
- 2
- 3
- 4
Craniotomy*
- 1
- 2
- 3
- 4
Laminectomy*
- 1
- 2
- 3
- 4
Shunt Procedures - VP/VA*
- 1
- 2
- 3
- 4
Plastics
Abdominoplasty/Abdominal Lipectomy*
- 1
- 2
- 3
- 4
Augmentation Mammoplasty*
- 1
- 2
- 3
- 4
Cleft Lip/Palate Repair*
- 1
- 2
- 3
- 4
Facelift*
- 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 Revision*
- 1
- 2
- 3
- 4
Skin Meshing*
- 1
- 2
- 3
- 4
Split Thickness Skin Grafting*
- 1
- 2
- 3
- 4
Eye
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 & 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
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
Thoracic
Hiatal Hernia*
- 1
- 2
- 3
- 4
Pneumonectomy/ Lobectomy*
- 1
- 2
- 3
- 4
Thoracotomy*
- 1
- 2
- 3
- 4
Endoscopic Thoracic Procedures*
- 1
- 2
- 3
- 4
Lung/Wedge Resection*
- 1
- 2
- 3
- 4
Endoscopy
Bronchoscopy*
- 1
- 2
- 3
- 4
Upper Endoscopy (EGD)*
- 1
- 2
- 3
- 4
Cystoscopy*
- 1
- 2
- 3
- 4
Gastroscopy*
- 1
- 2
- 3
- 4
Colonoscopy*
- 1
- 2
- 3
- 4
Cardiovascular
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
Coronary Artery Bypass Graft-off 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
Heart*
- 1
- 2
- 3
- 4
Pancreas*
- 1
- 2
- 3
- 4
Lung*
- 1
- 2
- 3
- 4
Liver*
- 1
- 2
- 3
- 4
Kidney*
- 1
- 2
- 3
- 4
Eye*
- 1
- 2
- 3
- 4
Equipment
Robotics*
- 1
- 2
- 3
- 4
List Types:
Fracture Tables*
- 1
- 2
- 3
- 4
List Types:
Video Systems*
- 1
- 2
- 3
- 4
List Types:
Sterilization of Equipment
Log*
- 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
Miscellaneous
Universal 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.*
Your Recruiter*
Name*
First Last
Email*
Phone*
Date*
MM slash DD slash YYYY

Skills Checklist

Age of Patients Cared For

GENERAL SKILLS

SCRUB EXPERIENCE WITH THE FOLLOWING

LAPAROSCOPIC PROCEDURES

GYNECOLOGY

G.U. AND CYSTO

Orthopedic

Neurosurgery

Plastics

Eye

Ear, Nose & Throat

Thoracic

Endoscopy

Cardiovascular

Transplants

Equipment

Sterilization of Equipment

Miscellaneous