Pediatric Competency Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your strengths within your specialty and assist the facility in the selection process of the healthcare professional.

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance) 4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

________________________________________________________________________________________________________ Print Name Last 4 Digits of SS# Date General Skills

Experience

Normal growth & development

0

1

2

3

4

5

Immunizations

0

1

2

3

4

5

Provide safe environment for age specific care

0

1

2

3

4

5

Recognize signs of failure to thrive

0

1

2

3

4

5

Recognize signs of abuse/neglect

0

1

2

3

4

5

Advanced directives

0

1

2

3

4

5

Awareness of HCAHPS

0

1

2

3

4

5

Patient/family teaching

0

1

2

3

4

5

Lift/transfer devices

0

1

2

3

4

5

Specialty beds

0

1

2

3

4

5

Restrictive devices (restraints)

0

1

2

3

4

5

End of life care/pallative care

0

1

2

3

4

5

Wound assessment & care

0

1

2

3

4

5

Automated Medication Dispensing System, Pyxis, Omnicell, or other

0

1

2

3

4

5

Bar coding for medication administration

0

1

2

3

4

5

Diabetic care & education

0

1

2

3

4

5

Blood Glucose Monitoring (BGM)

0

1

2

3

4

5

Insulin administration

0

1

2

3

4

5

National Patient Safety Goals

0

1

2

3

4

5

Accurate patient identification

0

1

2

3

4

5

Effective communication

0

1

2

3

4

5

Interpretation & communication of lab values

0

1

2

3

4

5

Medication administration (PO,IM,IV,PR)

0

1

2

3

4

5

Labeling (medications & specimens)

0

1

2

3

4

5

Medication reconciliation

0

1

2

3

4

5

Anticoagulation therapy

0

1

2

3

4

5

Monitoring conscious sedation

0

1

2

3

4

5

Pain assessment & management

0

1

2

3

4

5

Use of PCA (IV, intrathecal, epidural)

0

1

2

3

4

5

Infection control

0

1

2

3

4

5

Universal precautions

0

1

2

3

4

5

Isolation

0

1

2

3

4

5

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 1 of 7

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance)

Initials ___________

4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

General Skills - cont.

Experience

Minimize risk for falls

0

1

2

3

4

5

Prevention of pressure ulcers

0

1

2

3

4

5

Starting & maintaining peripheral IVs

0

1

2

3

4

5

Blood draw: venous

0

1

2

3

4

5

Central line care (includes Broviac/PICC/Groshong/Hickman)

0

1

2

3

4

5

Blood draw: central line

0

1

2

3

4

5

Care & management of ports

0

1

2

3

4

5

TPN & lipids

0

1

2

3

4

5

Administration of blood & blood products

0

1

2

3

4

5

Administration of chemotherapy

0

1

2

3

4

5

Monitoring chemotherapy (does not initiate)

0

1

2

3

4

5

IV Therapy

Cardiovascular

Experience

Pediatric assessment

0

1

2

3

4

5

Cardiac monitoring & emergency care

0

1

2

3

4

5

Obtains 12 lead EKG

0

1

2

3

4

5

Basic EKG interpretation

0

1

2

3

4

5

Use of rapid response teams

0

1

2

3

4

5

Cardiac arrest/CPR

0

1

2

3

4

5

Administration of PALS protocols & medications

0

1

2

3

4

5

Use of Broslow system

0

1

2

3

4

5

Cogenital heart defects

0

1

2

3

4

5

Congestive heart failure

0

1

2

3

4

5

Post cardiac cath

0

1

2

3

4

5

Post cardiac surgery

0

1

2

3

4

5

Cardiomyopathy

0

1

2

3

4

5

Pericarditis

0

1

2

3

4

5

Shock

0

1

2

3

4

5

Rheumatic fever

0

1

2

3

4

5

Heart transplant

0

1

2

3

4

5

Bacterial endocarditis

0

1

2

3

4

5

Antidysrythmics

0

1

2

3

4

5

Antihypertensives

0

1

2

3

4

5

Cardiac glycoside (digoxin)

0

1

2

3

4

5

Care of Child with:

Medications

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 2 of 7

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance)

Initials ___________

4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

Pulmonary

Experience

Respiratory assessment

0

1

2

3

4

5

Rate & work of breathing

0

1

2

3

4

5

Oral/nasal suctioning

0

1

2

3

4

5

Tracheostomy care and suctioning

0

1

2

3

4

5

Chest Physiotherapy (CPT)

0

1

2

3

4

5

Pulse oximeter

0

1

2

3

4

5

Ventilator management

0

1

2

3

4

5

O2 (NC/mask/oxyhood)

0

1

2

3

4

5

Assist with chest tube insertion & management

0

1

2

3

4

5

Asthma

0

1

2

3

4

5

RSV (Respiratory Syncytial Virus)

0

1

2

3

4

5

Bronchopulmonary Dysplasia (BPD)

0

1

2

3

4

5

Cystic fibrosis

0

1

2

3

4

5

Croup

0

1

2

3

4

5

Pneumonia

0

1

2

3

4

5

Epiglottitis

0

1

2

3

4

5

Tuberculosis

0

1

2

3

4

5

Alupent

0

1

2

3

4

5

Aminophylline (obsolete medication)

0

1

2

3

4

5

Ventolin

0

1

2

3

4

5

Inhaled corticosteroids

0

1

2

3

4

5

Respigam/synergis

0

1

2

3

4

5

Equipment & Procedures

Care of Child with:

Medications

Neurological

Experience

Pediatric neurological assessment

0

1

2

3

4

5

Assist with lumbar puncture

0

1

2

3

4

5

ICP monitoring

0

1

2

3

4

5

Battered child syndrome

0

1

2

3

4

5

Depression

0

1

2

3

4

5

TBI (Traumatic Brain Injury)

0

1

2

3

4

5

Encephalitis

0

1

2

3

4

5

Meningitis

0

1

2

3

4

5

Neuromuscular disease

0

1

2

3

4

5

Spinal cord injury

0

1

2

3

4

5

Care of Child with:

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 3 of 7

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance)

Initials ___________

4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

Neurological - cont.

Experience

Seizures

0

1

2

3

4

5

Hydrocephalus

0

1

2

3

4

5

VP shunt

0

1

2

3

4

5

Epilepsy

0

1

2

3

4

5

Near drowning

0

1

2

3

4

5

Stimulants (Ritalin, Adderall)

0

1

2

3

4

5

Steroids (Decadron, Solu-Medrol)

0

1

2

3

4

5

Anticonvulsants (Dilantin, phenobarbital)

0

1

2

3

4

5

Medications

Orthopedics Assessment of circulation checks

Experience 0

1

2

3

4

5

Devised traction (splints, casts, braces)

0

1

2

3

4

5

Pinned traction

0

1

2

3

4

5

Osteomylitis

0

1

2

3

4

5

Fractures

0

1

2

3

4

5

Post Harrington rod insertion

0

1

2

3

4

5

Equipment & Procedures

Care of Child with:

Gastrointestinal

Experience

GI assessment

0

1

2

3

4

5

Abdominal girth measurement

0

1

2

3

4

5

Feedings

0

1

2

3

4

5

Bottle

0

1

2

3

4

5

Breast

0

1

2

3

4

5

Gavage

0

1

2

3

4

5

Gastrostomy

0

1

2

3

4

5

Nasojejunal

0

1

2

3

4

5

Nasogastric and sump tubes to suction

0

1

2

3

4

5

Placement of oro/nasogastric tubes

0

1

2

3

4

5

Colostomy/ileostomy care

0

1

2

3

4

5

Anorexia/bulimia

0

1

2

3

4

5

Tracheoesophageal Fistula (TEF)

0

1

2

3

4

5

Gastroschisis/omphalocele

0

1

2

3

4

5

Necrotizing Enterocolitis (NEC)

0

1

2

3

4

5

Crohn’s disease

0

1

2

3

4

5

Equipment & Procedures

Care of Child with:

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 4 of 7

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance)

Initials ___________

4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

Gastrointestinal - cont.

Experience

Cleft lip/palate

0

1

2

3

4

5

Gastroenteritis

0

1

2

3

4

5

Pyloric stenosis

0

1

2

3

4

5

Ulcerative colitis

0

1

2

3

4

5

GE reflux

0

1

2

3

4

5

GI bleeding

0

1

2

3

4

5

Intestinal parasites

0

1

2

3

4

5

Small bowel transplant

0

1

2

3

4

5

Surgical abdomen

0

1

2

3

4

5

Renal/GU Assessment of fluid balance

Experience 0

1

2

3

4

5

Assist with suprapubic tap

0

1

2

3

4

5

Peritoneal dialysis

0

1

2

3

4

5

Insertion & care of Foley catheter

0

1

2

3

4

5

Glomerular nephritits

0

1

2

3

4

5

Ilial conduit ureteral

0

1

2

3

4

5

Nephrotic syndrome

0

1

2

3

4

5

Wilm’s tumor

0

1

2

3

4

5

UTI

0

1

2

3

4

5

Hemolytic uremic syndrome

0

1

2

3

4

5

Kidney transplant

0

1

2

3

4

5

Equipment & Procedures

Care of Child with:

Endocrine System

Experience

Care of Child with: Onset diabetes

0

1

2

3

4

5

Diabetic ketoacidosis

0

1

2

3

4

5

Adrenal disorders

0

1

2

3

4

5

Cushing’s syndrome

0

1

2

3

4

5

Pituitary disorders

0

1

2

3

4

5

Pancreas transplant

0

1

2

3

4

5

Thyroid malfunction

0

1

2

3

4

5

Insulin administration

0

1

2

3

4

5

Insulin pumps

0

1

2

3

4

5

Thyroid

0

1

2

3

4

5

Growth hormone

0

1

2

3

4

5

Medications

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 5 of 7

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance)

Initials ___________

4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

Hematology/Oncology Assist with bone marrow aspiration

Experience 0

1

2

3

4

5

Anemia

0

1

2

3

4

5

Bone marrow transplant

0

1

2

3

4

5

Leukemia

0

1

2

3

4

5

Sickle cell disease

0

1

2

3

4

5

Hemophilia

0

1

2

3

4

5

Malignant tumors

0

1

2

3

4

5

Spleen trauma/spleenectomy

0

1

2

3

4

5

Neutropenic fever

0

1

2

3

4

5

Sepsis

0

1

2

3

4

5

Hodgkin’s

0

1

2

3

4

5

Care of Child with:

Infectious Diseases

Experience

Care of Child with: Common childhood communicable diseases

0

1

2

3

4

5

HIV/CMV/AIDS

0

1

2

3

4

5

Hepatitis

0

1

2

3

4

5

Kawasaki disease

0

1

2

3

4

5

Age Specific Competencies

Experience

Newborn/neonate (birth-30 days)

0

1

2

3

4

5

Infants (31 days-1 year)

0

1

2

3

4

5

Toddler (ages 2-3 years)

0

1

2

3

4

5

Preschool (ages 4-5 years)

0

1

2

3

4

5

School age (ages 6-12 years)

0

1

2

3

4

5

Adolescent (ages 13-21 years)

0

1

2

3

4

5

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 6 of 7

Experience 0 Not Applicable 1 No Experience 2 Some Experience (Require Assistance) 3 Intermittent Experience (May Require Assistance)

Initials ___________

4 Experienced (Performs without Assistance) 5 Very Experienced (Able to Teach/Supervise)

Please list any Additional Skills: 1.

2.

3.

4.

Additional training: 1.

2.

3.

4.

Additional equipment: 1.

2.

3.

4.

Fax to: 1-888-298-3146 The information on this and all preceding pages is true and correct.

___________________________________________________________________________________________________ Signature Date

© 2015 Medical Staffing Network Rev. 06/15

F01205 Pediatric 7 of 7