First Name
This profile is for use by Critical Care Nurses with more than one year's experience in their discipline and specialty. It will not be a determining factor for the Nurse Providers, Inc. program. Return this checklist to us by mail or fax it to 650-301-3257.
Last Name
Social Security #
Directions: Please indicate your level of experience by selecting the correct number. Experience level:
1. No Experience 2. Minimal Experience - requires supervision/assistance
3. Competent 4. Very Experienced - proficient
A. PSYCHIATRIC
  1. Assessment
    1. Admission 1.    2.    3.    4.   
    2. Initial nursing assessment and care plan 1.    2.    3.    4.   
    3. Initial treatment plan 1.    2.    3.    4.   
    4. Neurological vital signs 1.    2.    3.    4.   
    5. Nursing diagnoses 1.    2.    3.    4.   
    6. Nursing reassessment and care planning update 1.    2.    3.    4.   
    7. Suicide risk assessment 1.    2.    3.    4.   
  2. Equipment & procedures
    1. Active participation in multidisciplinary staffing 1.    2.    3.    4.   
    2. Cardioversion 1.    2.    3.    4.   
    3. Cardiopulmonary resuscitation 1.    2.    3.    4.   
    4. Charge nurse experience 1.    2.    3.    4.   
    5. Charting
      1. Behavioristic 1.    2.    3.    4.   
      2. Treatment/goal oriented 1.    2.    3.    4.   
    6. Discharge Planning 1.    2.    3.    4.   
    7. Group therapy leader 1.    2.    3.    4.   
    8. Insertion & care of straight and Foley catheter
      1. Female 1.    2.    3.    4.   
      2. Male 1.    2.    3.    4.   
    9. Management of drug/alcohol detox symptoms 1.    2.    3.    4.   
    10. Management of assaultive behavior 1.    2.    3.    4.   
    11. Multi-disciplinary treatment team participation 1.    2.    3.    4.   
    12. O2 therapy & medication delivery systems
      1. Bag and mask 1.    2.    3.    4.   
      2. External CPAP 1.    2.    3.    4.   
      3. Face masks 1.    2.    3.    4.   
      4. Inhalers 1.    2.    3.    4.   
      5. Nasal cannula 1.    2.    3.    4.   
      6. Portable O2 tank 1.    2.    3.    4.   
      7. Trach collar 1.    2.    3.    4.   
    13. Oro-naso-pharynx suctioning 1.    2.    3.    4.   
    14. Participation in milieu therapy 1.    2.    3.    4.   
    15. Patient teaching 1.    2.    3.    4.   
    16. Psychiatric emergency response team 1.    2.    3.    4.   
    17. Rapid tranquilization 1.    2.    3.    4.   
    18. Restraints, application and assessment of:
      1. Ambulatory cuffs 1.    2.    3.    4.   
      2. Full restraints 1.    2.    3.    4.   
      3. Wrist restraints 1.    2.    3.    4.   
    19. Telephonic crisis intervention 1.    2.    3.    4.   
    20. Therapeutic communication skills 1.    2.    3.    4.   
    21. Tube feeding 1.    2.    3.    4.   
  3. Care of the patient with:
    1. Assaultive 1.    2.    3.    4.   
    2. Eating disorder 1.    2.    3.    4.   
    3. Hallucinations 1.    2.    3.    4.   
    4. Manic-depressive patient 1.    2.    3.    4.   
    5. Organic disorder 1.    2.    3.    4.   
    6. Substance abuse 1.    2.    3.    4.   
    7. Schizophrenic patient 1.    2.    3.    4.   
    8. Seclusion and restraints 1.    2.    3.    4.   
    9. Seizure disorder 1.    2.    3.    4.   
    10. Suicidal behavior 1.    2.    3.    4.   
    11. Tracheostomy 1.    2.    3.    4.   
  4. Medications
    1. Administration of oral psychotropic medications 1.    2.    3.    4.   
    2. Heparin 1.    2.    3.    4.   
    3. Intramuscular 1.    2.    3.    4.   
    4. Oral 1.    2.    3.    4.   
    5. Rectal 1.    2.    3.    4.   
    6. Sub-q 1.    2.    3.    4.   
    7. Unit dose 1.    2.    3.    4.   
    8. Z-technique 1.    2.    3.    4.   
B. PHLEBOTOMY/IV THERAPY
  1. Equipment & procedures
    1. Administration of blood/blood products
      1. Packed red blood cells1.    2.    3.    4.   
      2. Whole blood1.    2.    3.    4.   
    2. Drawing blood from central line 1.    2.    3.    4.   
    3. Drawing venous blood 1.    2.    3.    4.   
    4. Management of patient with hyperalimentation 1.    2.    3.    4.   
    5. Management of patient with IV 1.    2.    3.    4.   
    6. Starting IVs
      1. Angiocath1.    2.    3.    4.   
      2. Butterfly1.    2.    3.    4.   
      3. Heparin lock1.    2.    3.    4.   

Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.

Age Specific Criteria
A. Newborn/Neonatal (birth - 30 days) B. Infant (30 days - 1 year) C. Toddler (1-3 years)
D. Preschool (3-5 years) E. School Age Children (5-12 years) F. Adolescent (12-18 years)
G. Young Adults (18-39 years) H. Middle Adults (39-64 years) I. Older Adults (64+ years)

EXPERIENCE WITH AGE GROUPS: A B C D E F G H I
1. Able to assess age appropriate behavior, motor skills and physiological norms.
2. Able to adapt care according to normal growth and development.
3. Able to communicate and instruct patient according to their age, maturity and comprehension ability.
4. Able to provide a safe environment according to the specific needs of various age groups.
MY EXPERIENCE IS PRIMARILY IN
Burn Unit years Cardiac Care years Gynecology years
Neurology years Labor and Delivery years Medical years
Mother/Baby years Obstetrics years Orthopedics years
Oncology years Pediatrics years Post Partum years
Surgical years Rehabilitation years Telemetry years
EMERGENCY ROOM NURSERY PSYCHIATRY
Trauma Referral Center (Level I) years Newborn years Adolescent years
Community ER years Level II Nursery years Adult years
Rural ER years Level III Nursery years Chemical dependency/Detox years
OPERATING ROOM years
Circulate years
Scrub years

 

Upon submitting this form, I certify all of the foregoing information to be true, accurate and complete. I understand and acknowledge that any misrepresentation or omission of fact on this application may result in disqualification from employment with Nurse Providers, Inc., Inc. I authorize Nurse Providers, Inc. and its agents to conduct any investigation concerning my background, civil and criminal records, educational records and any other such records or information related to my potential employment with Nurse Providers, Inc.. If employed by Nurse Providers, Inc., I agree to abide by all rules and regulations adopted by Nurse Providers, Inc. and understand that those rules and regulations are subject to change from time to time. I understand that, if employed by Nurse Providers, Inc., I may be required to undergo a physical examination, including drug screening, in order to determine my ability to perform the duties required in my position. I hereby authorize my former employers to release to Nurse Providers, Inc. and its agents any and all information concerning my past employment.