Registered Nurse First Assist (RNFA) 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 independentlyGENERAL SKILLSAdvanced directives(Required) 1 2 3 4 Patient / family teaching(Required) 1 2 3 4 Restrictive devices (restraints)(Required) 1 2 3 4 Lift / transfer devices(Required) 1 2 3 4 Specialty beds(Required) 1 2 3 4 End of life care / palliative care(Required) 1 2 3 4 Wound assessment & care(Required) 1 2 3 4 Automated Medication Dispensing System, Pyxis, Omnicell, or other(Required) 1 2 3 4 Bar coding for medication administration(Required) 1 2 3 4 Diabetic care and education(Required) 1 2 3 4 Blood Glucose Monitor (BGM)(Required) 1 2 3 4 Cardioversion / defibrillation(Required) 1 2 3 4 Electronic ICU(Required) 1 2 3 4 National Patient Safety Goals(Required) 1 2 3 4 Accurate patient identification(Required) 1 2 3 4 Effective communication(Required) 1 2 3 4 Interpretation & communication of lab values(Required) 1 2 3 4 Medication administration(Required) 1 2 3 4 Medication reconciliation(Required) 1 2 3 4 Labeling (medications & specimens)(Required) 1 2 3 4 Anticoagulation therapy(Required) 1 2 3 4 Monitoring conscious sedation(Required) 1 2 3 4 Pain assessment & management(Required) 1 2 3 4 Infection control(Required) 1 2 3 4 Universal precautions(Required) 1 2 3 4 Isolation(Required) 1 2 3 4 Minimize risk for falls(Required) 1 2 3 4 Prevention of pressure ulcers(Required) 1 2 3 4 Use of rapid response teams(Required) 1 2 3 4 Awareness of HCAHPS(Required) 1 2 3 4 GENERAL SKILLS EXPERIENCECardiac arrest/adult CPR infant-child CPR(Required) 1 2 3 4 Advanced directives(Required) 1 2 3 4 Awareness of HCAHPS(Required) 1 2 3 4 Patient/family teaching(Required) 1 2 3 4 Lift/transfer devices(Required) 1 2 3 4 Specialty beds(Required) 1 2 3 4 Restrictive devices(Required) 1 2 3 4 End of life care/palliative care(Required) 1 2 3 4 Automated Medication Dispensing System, Pyxis, Omnicell, or other(Required) 1 2 3 4 Bar coding for medication administration(Required) 1 2 3 4 Diabetic management in the OR(Required) 1 2 3 4 National Patient Safety Goals(Required) 1 2 3 4 Accurate patient identification/surgical site verification with OR team(Required) 1 2 3 4 Effective communication(Required) 1 2 3 4 Interpretation & timely communication of lab values(Required) 1 2 3 4 Labeling (medications & specimens)(Required) 1 2 3 4 Medication reconciliation(Required) 1 2 3 4 Anticoagulant therapy(Required) 1 2 3 4 Monitoring conscious sedation(Required) 1 2 3 4 MDRO HAI(Required) 1 2 3 4 Hand hygiene WHO/CDC(Required) 1 2 3 4 CLABSI infections(Required) 1 2 3 4 CAUTI prevention(Required) 1 2 3 4 Identify patient suicide risk(Required) 1 2 3 4 Universal protocol(Required) 1 2 3 4 Surg site infection control(Required) 1 2 3 4 GENERAL SURGERYBowel resection(Required) 1 2 3 4 Cholecystectomy/cholangiogram(Required) 1 2 3 4 Colostomy/ileostomy(Required) 1 2 3 4 Gastrectomy(Required) 1 2 3 4 Hemicolectomy(Required) 1 2 3 4 Hepatic resection(Required) 1 2 3 4 Herniorrhaphy-femoral/inguinal(Required) 1 2 3 4 Hiatal herniorrhaphy(Required) 1 2 3 4 Pancreatectomy(Required) 1 2 3 4 Organ procurement(Required) 1 2 3 4 Radical mastectomy(Required) 1 2 3 4 Saphenous vein ligation/stripping(Required) 1 2 3 4 Splenectomy(Required) 1 2 3 4 Thyroidectomy(Required) 1 2 3 4 Tracheostomy(Required) 1 2 3 4 Vagotomy(Required) 1 2 3 4 Familiarity with pediatric procedures(Required) 1 2 3 4 Abdominal perineal resection(Required) 1 2 3 4 Adrenalectomy bariatric surgery (gastric bypass)(Required) 1 2 3 4 ENDOSCOPYBronchoscopy(Required) 1 2 3 4 Colonoscopy(Required) 1 2 3 4 Culdoscopy(Required) 1 2 3 4 Cystoscopy(Required) 1 2 3 4 Esophagoscopy(Required) 1 2 3 4 Gastroscopy(Required) 1 2 3 4 Hysteroscopy(Required) 1 2 3 4 GYNECOLOGYCaesarean Section(Required) 1 2 3 4 Dilation & Curettage(Required) 1 2 3 4 Hysterectomy - Vaginal(Required) 1 2 3 4 Hysterectomy - Abdominal(Required) 1 2 3 4 Radium Insertion(Required) 1 2 3 4 Salpingo-Oopherectomy(Required) 1 2 3 4 Shirodkar Procedure(Required) 1 2 3 4 Termination Of Pregnancy(Required) 1 2 3 4 Tubal ligation(Required) 1 2 3 4 Vaginectomy(Required) 1 2 3 4 LAPAROSCOPIC PROCEDURESAppendectomy(Required) 1 2 3 4 Cholecystectomy(Required) 1 2 3 4 Colon resection(Required) 1 2 3 4 Gastric bypass(Required) 1 2 3 4 Hernia repair(Required) 1 2 3 4 Nephrectomy(Required) 1 2 3 4 Prostatectomy(Required) 1 2 3 4 Sinus surgery(Required) 1 2 3 4 Salpingo-oophorectomy(Required) 1 2 3 4 Splenectomy(Required) 1 2 3 4 Tubal ligation(Required) 1 2 3 4 Vaginal hysterectomy(Required) 1 2 3 4 Laryngoscopy(Required) 1 2 3 4 Mediastinoscopy(Required) 1 2 3 4 Pelviscopy(Required) 1 2 3 4 Sigmoidoscopy(Required) 1 2 3 4 Thoracoscopy(Required) 1 2 3 4 Whipple(Required) 1 2 3 4 Nissen fundoplication(Required) 1 2 3 4 ORTHOPEDICAchilles tendon repair(Required) 1 2 3 4 Amputation(Required) 1 2 3 4 Arthroscopy/anthrotomy(Required) 1 2 3 4 Closed pinning & reduction of extremities(Required) 1 2 3 4 External compression devices(Required) 1 2 3 4 Hip compression nails & lag screws(Required) 1 2 3 4 Total joint replacement - knee(Required) 1 2 3 4 Total joint replacement - hip(Required) 1 2 3 4 Total joint replacement - shoulder(Required) 1 2 3 4 Spica cast(Required) 1 2 3 4 ORIF - shoulder, hip, humerus(Required) 1 2 3 4 Repair of dislocation(Required) 1 2 3 4 Patellectomy(Required) 1 2 3 4 Tendon implants & reanastomosis(Required) 1 2 3 4 UROLOGYCircumcision(Required) 1 2 3 4 Cystoscopy/ureteroscopy(Required) 1 2 3 4 Cystectomy(Required) 1 2 3 4 Hypospadias repair(Required) 1 2 3 4 Implants(Required) 1 2 3 4 Lithotripsy(Required) 1 2 3 4 Nephrectomy(Required) 1 2 3 4 Orchiectomy(Required) 1 2 3 4 Prostatectomy(Required) 1 2 3 4 Ureterolithotomy(Required) 1 2 3 4 TURP(Required) 1 2 3 4 PVP - Photo Vaporization of Prostate(Required) 1 2 3 4 Vasectomy(Required) 1 2 3 4 NEUROLOGYKyphoplasty(Required) 1 2 3 4 A-V malformation(Required) 1 2 3 4 Laparoscopic spine procedures(Required) 1 2 3 4 Burr holes for subdural hematoma(Required) 1 2 3 4 Carotid ligation(Required) 1 2 3 4 Cervical sympathectomy(Required) 1 2 3 4 Cranioplasty(Required) 1 2 3 4 Craniotomy(Required) 1 2 3 4 Disectomy/laminectomy(Required) 1 2 3 4 Halo traction application(Required) 1 2 3 4 Insertion of nerve stimulator(Required) 1 2 3 4 Myelomeningocele repair(Required) 1 2 3 4 Shunt procedure(Required) 1 2 3 4 Spinal fusions(Required) 1 2 3 4 Ventriculostomy(Required) 1 2 3 4 PLASTICSAbdominal lipectomy(Required) 1 2 3 4 Blepharoplasty(Required) 1 2 3 4 Face lift(Required) 1 2 3 4 Mammoplasty(Required) 1 2 3 4 Augmentation(Required) 1 2 3 4 Reduction(Required) 1 2 3 4 Liposuction(Required) 1 2 3 4 Otoplasty(Required) 1 2 3 4 Scar revisions(Required) 1 2 3 4 Skin grafting(Required) 1 2 3 4 OPTHOMOLOGYCataract extraction(Required) 1 2 3 4 IOL implants(Required) 1 2 3 4 Corneal transplant(Required) 1 2 3 4 Orbital implant(Required) 1 2 3 4 Enucleation(Required) 1 2 3 4 Repair of retinal detachment(Required) 1 2 3 4 Scleral buckle(Required) 1 2 3 4 EAR, NOSE & THROATCaldwell-luc(Required) 1 2 3 4 Cleft lip/palate repair(Required) 1 2 3 4 Laryngectomy(Required) 1 2 3 4 Radical neck(Required) 1 2 3 4 Tonsillectomy & adenoidectomy(Required) 1 2 3 4 Mandibulectomy(Required) 1 2 3 4 Mastoidectomy(Required) 1 2 3 4 Rhinoplasty/septoplasty(Required) 1 2 3 4 Sinusotomy(Required) 1 2 3 4 VASCULARAngiography(Required) 1 2 3 4 A-V access graft(Required) 1 2 3 4 Aortic aneurysm: abdominal(Required) 1 2 3 4 Peripheral vascular bypass procedures(Required) 1 2 3 4 Endarterectomy: carotid(Required) 1 2 3 4 Thrombectomy(Required) 1 2 3 4 Embolectomy(Required) 1 2 3 4 Vena cava ligation(Required) 1 2 3 4 ENDOVASCULAREndoluminal AAA(Required) 1 2 3 4 Carotid revascularization endarterectomy(Required) 1 2 3 4 Cerebral aneurysm repair(Required) 1 2 3 4 TRANSPLANTBone(Required) 1 2 3 4 Corneal(Required) 1 2 3 4 Harvesting(Required) 1 2 3 4 Heart/lung(Required) 1 2 3 4 Kidney(Required) 1 2 3 4 Liver(Required) 1 2 3 4 Multi organ(Required) 1 2 3 4 Pancreas(Required) 1 2 3 4 Skin(Required) 1 2 3 4 THORACIC/CARDIOVASCULARAortic femoral bypass graft(Required) 1 2 3 4 Femoral popliteal bypass(Required) 1 2 3 4 Pacemaker implantation/explanation(Required) 1 2 3 4 Care of patients with pacemaker(Required) 1 2 3 4 Care of patients with intra-aortic balloon pump(Required) 1 2 3 4 Septal defects, ASV, VSD(Required) 1 2 3 4 Coronary Artery Bypass & Graft (CABG) on pump(Required) 1 2 3 4 Valve replacement/repair(Required) 1 2 3 4 Aortic aneurysm(Required) 1 2 3 4 Thoracotomy/lobectomy(Required) 1 2 3 4 Endoscopic vein harvesting(Required) 1 2 3 4 Maze procedure(Required) 1 2 3 4 Maze procedureBurns(Required) 1 2 3 4 Gunshot/stab wounds(Required) 1 2 3 4 Motor vehicle accidents(Required) 1 2 3 4 Traumatic amputations(Required) 1 2 3 4 EQUIPMENTArgon beam coagulator(Required) 1 2 3 4 Camera/video systems(Required) 1 2 3 4 Cell saver(Required) 1 2 3 4 Cidex soak(Required) 1 2 3 4 Cryo-ophthalmic unit(Required) 1 2 3 4 Cavitron Ultrasonic Surgical Aspirator (CUSA)(Required) 1 2 3 4 Hypo/hyperthermia unit(Required) 1 2 3 4 Drill and saws(Required) 1 2 3 4 Electrosurgical unit(Required) 1 2 3 4 Fiber optic luminator(Required) 1 2 3 4 Cavitron(Required) 1 2 3 4 Autoclave(Required) 1 2 3 4 Fracture tables(Required) 1 2 3 4 Harmonic scalpel(Required) 1 2 3 4 Ligasure(Required) 1 2 3 4 Stapling devices(Required) 1 2 3 4 Mesh graft/dermatone(Required) 1 2 3 4 Microscopes(Required) 1 2 3 4 Nitrogen tank(Required) 1 2 3 4 Pneumatic tourniquet(Required) 1 2 3 4 Stealth(Required) 1 2 3 4 Steris unit(Required) 1 2 3 4 Pulsevac irrigation(Required) 1 2 3 4 Autotransfusion system(Required) 1 2 3 4 Laser equipment(Required) 1 2 3 4 Care of scopes & fberoptic equipment(Required) 1 2 3 4 Venodyne robotics (Da Vinci)(Required) 1 2 3 4 PROCEDURAL SKILLS (In Collaboration with Team/Surgeon)Position patient(Required) 1 2 3 4 Surgical draping(Required) 1 2 3 4 Creates sterile field(Required) 1 2 3 4 Maintains sterile field(Required) 1 2 3 4 Provides wound exposure(Required) 1 2 3 4 Use of instruments(Required) 1 2 3 4 Use of retractors(Required) 1 2 3 4 Suctioning and sponging techniques(Required) 1 2 3 4 Use of medical devices(Required) 1 2 3 4 Use of medications/solutions(Required) 1 2 3 4 Clamping blood vessels(Required) 1 2 3 4 Coagulating bleeding points(Required) 1 2 3 4 Ligating vessels(Required) 1 2 3 4 Other procedures in collaboration with surgeon(Required) 1 2 3 4 Safe tissue handling(Required) 1 2 3 4 Safe cutting of tissue(Required) 1 2 3 4 Suturing muscle(Required) 1 2 3 4 Suturing fascia(Required) 1 2 3 4 Suturing subcutaneous tissue(Required) 1 2 3 4 Suturing skin tissue(Required) 1 2 3 4 Assist with dressings/drains(Required) 1 2 3 4 Placing drains(Required) 1 2 3 4 Assist with cannulation(Required) 1 2 3 4 Assist with decannulation(Required) 1 2 3 4 Knot tying(Required) 1 2 3 4 Assists: SC local anesthesia(Required) 1 2 3 4 Preop nursing assessment(Required) 1 2 3 4 Periop nursing assessment(Required) 1 2 3 4 Write preop orders per hospital protocol(Required) 1 2 3 4 Environmental sanitation(Required) 1 2 3 4 Monitors surgical environment(Required) 1 2 3 4 Controls surgical environment(Required) 1 2 3 4 Working knowledge of equipment(Required) 1 2 3 4 Laser safety(Required) 1 2 3 4 Working knowledge of supplies(Required) 1 2 3 4 Sponge, needle, instrument count(Required) 1 2 3 4 Write post-op protocol orders per hospital protocol(Required) 1 2 3 4 Write operative notes per hospital protocol(Required) 1 2 3 4 Participate in postop rounds & D/C planning(Required) 1 2 3 4 Electrosurgery experience(Required) 1 2 3 4 Recognize & intervene for safety hazards(Required) 1 2 3 4 AGE-SPECIFIC COMPETENCIES EXPERIENCENewborn/neonate (birth-30 days)(Required) 1 2 3 4 Infant (31 days- 1 year)(Required) 1 2 3 4 Toddler (ages 2-3 yrs)(Required) 1 2 3 4 Preschool (ages 4-5 yrs)(Required) 1 2 3 4 School Age (ages 6-12 yrs)(Required) 1 2 3 4 Adolescent (ages 13-21 yrs)(Required) 1 2 3 4 Young Adult (ages 22-39)(Required) 1 2 3 4 Adult (ages 40-64)(Required) 1 2 3 4 Older Adult (ages 65+)(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. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. 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. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
