Intermediate Care One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyCARDIACAcute Coronary Syndrome(Required) 1 2 3 4 Post Open Heart (12-24 hours)(Required) 1 2 3 4 Post Vascular Surgery(Required) 1 2 3 4 Pacemaker - Temporary/Permanent(Required) 1 2 3 4 Sheath Removal(Required) 1 2 3 4 Congestive Heart Failure(Required) 1 2 3 4 Carotid Endarterectomy(Required) 1 2 3 4 Heart Transplant(Required) 1 2 3 4 Pacemaker - Epicardial(Required) 1 2 3 4 Heart Sounds(Required) 1 2 3 4 PULMONARYPneumonia(Required) 1 2 3 4 COPD(Required) 1 2 3 4 Post Thoracic Surgery(Required) 1 2 3 4 Trach Management(Required) 1 2 3 4 Intubation/Extubation(Required) 1 2 3 4 Interpretation of Arterial Blood Gases(Required) 1 2 3 4 Respiratory Distress(Required) 1 2 3 4 Breath Sounds(Required) 1 2 3 4 Chest Tube Placement & Management(Required) 1 2 3 4 Modes of Ventilation (AC/PC/SIMV/CPAP)(Required) 1 2 3 4 External CPAP/BiPAP(Required) 1 2 3 4 NEUROLOGIC & PSYCHIATRICStroke Scale Assessment(Required) 1 2 3 4 Brain Injury(Required) 1 2 3 4 Spinal Cord Injury(Required) 1 2 3 4 ETOH/Drug Withdrawal(Required) 1 2 3 4 CVA(Required) 1 2 3 4 Post Craniotomy(Required) 1 2 3 4 Seizure Disorders(Required) 1 2 3 4 GASTROINTESTINALGI Bleeding(Required) 1 2 3 4 Liver Failure(Required) 1 2 3 4 Liver Transplant(Required) 1 2 3 4 Liver Transplant(Required) 1 2 3 4 GI Surgery(Required) 1 2 3 4 Pancreatitis(Required) 1 2 3 4 Pancreas Transplant(Required) 1 2 3 4 RENAL/GENITOURINARYRenal Failure(Required) 1 2 3 4 Renal Transplant(Required) 1 2 3 4 Nephrostomy Tubes(Required) 1 2 3 4 Renal Surgery(Required) 1 2 3 4 Arteriovenous Fistula/Shunt(Required) 1 2 3 4 Peritoneal Dialysis(Required) 1 2 3 4 ENDOCRINE METABOLICDiabetes - Hypo/Hyperglycemic Crisis(Required) 1 2 3 4 IV Insulin Protocols(Required) 1 2 3 4 Pituitary Disorders(Required) 1 2 3 4 Indwelling Insulin Pumps(Required) 1 2 3 4 MEDICATIONSAnti- Arrhythmics(Required) 1 2 3 4 Anti-Hypertensives(Required) 1 2 3 4 Anti-Seizure Medications(Required) 1 2 3 4 Procedural Sedation(Required) 1 2 3 4 Emergency Medications(Required) 1 2 3 4 Insulin(Required) 1 2 3 4 Manage Vasoactive Drips - No Titration(Required) 1 2 3 4 Nitrates (Oral & Topical)(Required) 1 2 3 4 Reversal Agents(Required) 1 2 3 4 Automated Medication Dispensing (i.e. Pyxis, Omnicell)(Required) 1 2 3 4 Anticoagulants (IV, oral & injection)(Required) 1 2 3 4 Anti-Psychotics(Required) 1 2 3 4 Benzodiazepines(Required) 1 2 3 4 Diuretics(Required) 1 2 3 4 Inhaled Medications(Required) 1 2 3 4 Titrate Vasoactive Drips(Required) 1 2 3 4 Narcotics/Opioid Analgesics (IV, oral & injection)(Required) 1 2 3 4 Non-Opioid Analgesics (IV, Oral & Injection)(Required) 1 2 3 4 Steroids (IV, Oral, Inhaled)(Required) 1 2 3 4 IV THERAPYStarting Ivs(Required) 1 2 3 4 Central Line/Implanted Line Care(Required) 1 2 3 4 TPN & Lipids(Required) 1 2 3 4 Administration of Chemotherapy(Required) 1 2 3 4 Central Line Blood Draws(Required) 1 2 3 4 Arterial Line Management(Required) 1 2 3 4 Blood Product Administration(Required) 1 2 3 4 Blood Product AdministrationDysrhythmia Interpretation(Required) 1 2 3 4 Obtain 12 Lead EKG(Required) 1 2 3 4 Cardioversion(Required) 1 2 3 4 Malignant Hyperthermia(Required) 1 2 3 4 Dysrhythmia Management(Required) 1 2 3 4 Interpret 12 Lead EKG(Required) 1 2 3 4 Defibrillation(Required) 1 2 3 4 PROFESSIONAL KNOWLEDGE AND SKILLSNational Patient Safety Goals/Core Measures(Required) 1 2 3 4 Pressure Ulcer Risk Assessment/Prevention(Required) 1 2 3 4 Patient/Family Teaching(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 Pain Assessment & Management(Required) 1 2 3 4 Interpretation and Communication of Lab Values(Required) 1 2 3 4 Fall Risk Assessment/Prevention(Required) 1 2 3 4 Restraints/Use of Least Restrictive Device(Required) 1 2 3 4 Age Specific/Population-Based Care(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 Charge Experience(Required) 1 2 3 4 Specialty Beds(Required) 1 2 3 4 EMREpic(Required) 1 2 3 4 Eclipsys(Required) 1 2 3 4 Meditech(Required) 1 2 3 4 Computerized Physician Order Entry(Required) 1 2 3 4 Cerner(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Other Computerized System(Required) 1 2 3 4 Bar Coding for Medication Administration(Required) 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year)(Required) 1 2 3 4 Preschooler (ages 2-5 years)(Required) 1 2 3 4 Childhood (ages 6-12 years)(Required) 1 2 3 4 Adolescents (ages 13-21 years)(Required) 1 2 3 4 Young Adults (ages 22-39 years)(Required) 1 2 3 4 Adults (ages 40-64 years)(Required) 1 2 3 4 Older Adults (ages 65-79 years)(Required) 1 2 3 4 Elderly (ages 80+ years)(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. 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In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. 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