SF Bay Area:
t: (415) 332-4006

Outside Areas:
t: (707) 265-9180
f: (707) 265-9182
toll free: (800) 603-6664

Surgistaff, Medical Division

DIRECTIONS: By completing this checklist to the best of your ability, you will help us match your skills and areas of interest with our available assignments. Please circle the number, 1, 2, 3, or 4, that most accurately describes your level of experience with each skill. Please circle either ‘S’ or ‘C’ to indicate Scrub or Circulation experience. Print and fax your list to 707/265-9182

EXPERIENCE LEVELS
4 = VERY EXPERIENCED (can perform well independently))
3 = EXPERIENCED (Need initial review, then can perform independently)
2 = SOME EXPERIENCE (Require assistance/supervision)
1 = NO EXPERIENCE

OR Nursing Skills Checklist

Personal Information

Please enter your name:

Email:

Phone:

Years as RN?

Years as OR Nurse?

Strongest areas of expertise:

Weakest areas of expertise:

General Surgery

Procedure

Skill Level

Experience

AKA/BKA (amputation)

Radical Mastectomy

Abdominal-Perineal Resection

Cholecystectomy (Open)

Exploratory Laparotomy

Appendectomy

Laparoscopic Procedures

Cholecystectomy

Appendectomy

Laparoscopic Procedure-Hernia

Laparoscopic Procedure-Nissan

Laparoscopic Procedure-Colectomy

Gastrectomy

Inguinal/Ventral Hernia Repair

Spienectomy

Bowel Resection/Colostomy

Thyroidectomy

Rectal Procedures

Esophagascopy/Gastroscopy

Pediatric-Inguinal Hernia Repair

Pediatric-Pyloric Stenosis

Pediatric-Circumcision

Pediatric-Exploratory Laparotomy

Vascular Surgery

Carotid Endarterectomy

Abdominal Aortic Aneurysm

Femoral-Popliteal By-pass Graft

Insitu

Graph

Portacath, Tesio, Hickman

AV Shunt

Thrombecomy

Pacemaker Insertion

Arterial Stenting/Intra-Operative Angioplasty

Cardiac/Thoracic/Vascular

Subclavin/Carotid By-pass

Coronary Artary By-pass

Mitral Valve Repair/Replacement

Aortic Valve Replacement

Multiple Valve Transposition

Septal Defects

Ventricular Aneurysm Repair

Bring Back Heart

Pericardial Window

Intra-Aortic Balloon Insertion

Heartport or Similar CABG

Thoraco approach Mid-Cab

Aortic Arch Replacement/Valve Conduit

Mechanical Heart/LVAD

Pediatric Hearts

Tetrology of Fallot

Chamberlain Procedure

Femoral Artery Cannulation

AICD Insertion

Saphenous Vein Harvest

Endoscopic Vein Harvest

Gastric Artery Harvest

Radial Vein Harvest

Carotid Endarterectomy

Abdominal Aortic Aneurysm

Femoral-Popliteal By-pass Graft

Thrombectomy

AV Shunt

Pacemaker Insertion

Insertion Vena cava Filter

Portacath, Tesio, Hickman Placement

Thoracotomy

Thoracoscopy

Insertion Chest Tubes

Esophageal Repair

Pneurnonectorny/Lobectomy

Mediastinodcopy

Desendind Aortic Repair

Arterial Stenting/Intra-Operative Angiopiasty

Orthopedics

Total Hip Replacement

Bipolar Hip

Compression Hip Screw

Total Knee Replacement

Knee Arthoscopy

ACL Knee Repair

Harrington Rod or Similar

I.M. Rodding

Hand & Foot Procedures

Mini, Standard, Large Fragment Screws & Plates

External Fixation

Shoulder Repair

Sholder Arthoscopy

Spinal Fusion

Cast Application

Fracture Table Set-up

Drills, Saws and Reamers

Gynecology

D&C

Diagnostic Laparascope

Laparoscopic Assisted Vaginal Hysterectomy

Abdorninal Hysterectorny

Varinal Hysterectorny

Anterior/Posterior Repair

MMK(Marshall Marchetti Krantz)

Tuboplasty

BTL(Bilateral Tubal Ligation)

C-Sections

Urology

Radical Prostatectomy

Radical Lymph Node Dissection

Insertion Penile Prostesis

Hydrocelectomy

Cystoscopy

Ureteroscopy

TURP/TURST

Ultrasonic Lithotripsy

Neurology

Cervical Laminectomy(Anterior)

Cervical Laminectomy(Posterior)

Lumbar Laminectomy, Discectomy

Percutaneous Micro Discectomy

Craniotomy For Tumor

Craniotomy For Aneurysm

Burr Holes

VP Shunts

Transphenoidal Hypothypectomy

Carpal Tunnel Repair

Harrington Rod or Similar

Plastics

Mammoplasty

Facelifts

Skin Grafts

Rhinopiasty

Cleft Lip Repair

Abdorninalplasty

Blepharopiasty

Otoplasty

Muscle Flaps

E.N.T.

Middle Ear Cases

T&A

Myringotomy

Tympanoplasty

Radical Neck Dissection

Septoplasty

Sinus Endoscopy

Trauma Surgery

Transplant Surgery

Organ Procurement (Harvest)

Thoracic Surgery

Thoracotomy

Thoracoscopy

Insertion Chest Tubes

Esophageal Repair

Pneumonectomy/Lobectomy

The information I have given is true and accurate to the best of my knowledge.

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