Please list any limitations or comments you may have on a separate sheet.

IDENTIFYING
INFORMATION

Last Name
 First Name
 Middle Name
 Previous Sir Name
Social Security Number
CERTIFICATION
Exam Date Taken Certification
LICENSES
Original State License
License Number
Expiry Date
State License
License Number
Expiry Date
State License
 License Number
 Expiry Date
 State License
 License Number
 Expiry Date
State License
 License Number
 Expiry Date
 State License
 License Number
 Expiry Date
CLINICAL
SKILLS
List all slates in which vow are or leave ever been licensed beginning with your original state license.
Please rate your skills in the areas below, using the following values:
1 = No experience, 2 = Some experience (Less than one year), 3 = Experienced (1 year or more), 4 = Highly experienced (2 year or more)
Work Settings 1 2 3 4
Intensive care unit
Coron care unit
Pediatrics
Pediatrics ICU
NeonatalNeonatal ICU Level II
Neonatal ICU Level III
Emergency Room
Pulmonary Rehabilitation
Sleep Lab
Home Care
Transports
Therapeutics & Procedures 1 2 3 4
Oxygen set up: Nasal
Oxygen set up: Masks
Oxygen set up: Trach
Aerosol set up/mask/trach
Aerosol heated/cool
Oxygen tank set up
Croup tent set up/ troubleshoot
Infant hood set up
Analyze oxygen
Intubate adult
Intubate infant
Assist with intubation
Extubate
Assist with extubation
Assist with high-risk delivery
Nasotracheal suctionEndotracheal
SuctionVentilate patient with manual resuscitator
Check intracuff pressures
Change/clean trach tubes
Oral airway placement
Nasal airway placement
Isolation procedures
Disinfection and sterile techniques
Incentive spirometry
High-frequency ventilator
Inverse ration ventilation
IPPB
Hand held nebulizers
Ultrasonic nebulizer
Chest physical herapy/postural
Drainage
Splinting
Medihaler
Pursed lip breathing
Inhaler reservoirs (inspirease/aerochamber)
Diaphramatic breathing
Segmental breathing
Ventilator set up
Troubleshoot ventilators 1 2 3 4
Ventilator set up/on tanks
Negative inspiratory force
Vital capacity
Nasal CPAP
Assist/control
Control
CPAP
IMV
SIMV
PEEP
High-frequency ventilator
Inverse ration ventilation
Pulmonary stress testing
Pulmonary function testing
Bedside screening
Peak flow rate
Apnea monitor
Oximetry
Transcutaneous monitoring
Assist with bronchoscopies
Arterial blood gases: Allen test
Arterial blood gases: analyzing
Arterial blood gases: interpretation
Drawing radial artery
Drawing brachial artery
Drawing femoral artery
Drawing artial line
Set up &calibration of arterial lines
Balloon pump
Cardiac output monitoring
EEG
EKG
Adult resuscitation
Adult advanced life support
Pediatric resuscitation
Pediatric advanced life support
Neonatal advancecl 1ife support
Sechrist-Infant Star
Medications 1 2 3 4
Racemic epinephrine (Vaponephrine)
Isoproterenol ( Isuprel)
Isoetharine (Bronkosil)
Metaproterenal (Alupent)
Salbutamol (Albuterol, Proventil, Ventolin)
Terbuitaline sulfate (Brycanyl)
Atropine sulfate
Mucomyst
Bicarbonate
Cremolyn sodium (Intal)
Aerobid, vanceril
Azmacort
Familiarity With: 1 2 3 4
Theo-dur
Corticosteroids
Atropine
Digitalis
Digoxin
Lidocaine
Nipride
Dopamine
Pavulon
Anectine
Valium
Morphine Sulphate
Knowledge & Care of Patients With: 1 2 3 4
Asthma
Status asthmaticus
Acute chronic bronchitis
Broncho-pulmonary dysplasia (BPD)
Cardiac surgery
Cystic tthrosis
Epiglottitis
Failure to thrive
Respiratory distress syndrome
Thracheo-esophageal fistula
Hyaline membrane disease (HMD/IRDS)
Meconium aspiration
Neonatal pneumonia
Persistent fetal circulation
         
         
         
         
         
         
         




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