SELF EVALUATION
OR SKILLS PROFICIENCY CHECKLIST

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If you prefer, you can print a form to fax or mail.
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     Last Name: 
    First Name: 
Middle Initial: 
 Years Experience

DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.

LEVELS OF PROFICIENCY KEY:

0 =

No Experience

 3 =

Performs well, can act as a resource person
1 =

Minimal Experience, need supervision

 4 = Scrub
2 =

Can perform without supervision

 5 = Circulate
General Skills: 0 1 2 3 4 5
Radical Mastectomy
Rectal Cases
Abdominal – Perineal Resection
Cholecystectomy
Minor Cases Set – Up (breast biopsies, hernias)
Nissen Fundoplication
Thyroidectomy
Leveen – Peritoneal Shunt
Colon Resection
Staging Laporotomy
Vascular:
Aortia’illiac/Femoral Graft
Arotic Aneurysm
Thrombectomy
Femoral-Popliteal Graft
Carotid Endartectomy
Mohin-Uddin Umbrella
Leaking Ruptured Aneurysm
Trauma:
Gunshot Wounds
     Chest
     Abdomen
Motor Vehicle Accidents (multiple injuries)
Traumatic Amputations
Urology:
Nephrectozmy
Pyelolithotomy
Scott Penile Prosthesis
Soot Incontinence Device
Vasovasostomy
Radical Node Dissection
Oral:
TMJ Exploration
LaFort Osteotomies
Maxillary Procedure with Graft
TMJ with Arthroplasty
Fractured Jaws, Mandibular and Zagomatic
Transplant:
Cadaver Kidney Recovery (Harvest)
Kidney Transplant Recipient
Kidney Transplant Donor
Brachio Axillary Darcon Fistula
A-V Fistula Shunt
Trenckhoff Catheter Placement
Spleenectomy
Ear, Nose and Throat:
T and A Myringotomies
Ear Cases
     Tympanopiasty
     Mastoidectomy
     Stapedectomy
Acoustic Neuroma
Rhinoplasty
Frontal Sinus Trephing
Endoscopies
Vocal Cord Stripping
Thoracic & Open Heart: 0 1 2 3 4 5
Pacemaker Insertion
Thoracotomy
Open Heart Procedures
     ASD – Atrial Septal Defect
     VSD – Ventral or Ventricular Septal Defect
     Mitral or Aortic Valve Replacement
     Tetrology of Follet
     Patent Ductus Arteriosis
Chamberlain Procedure
OME
Neurology:
Cervical Laminectomy
Transphenoid Hypothypectomy
Carotid Endartectomy
VA and VP Shunt
Acoustic Neuroma
Craniotomy
Lumbar Laminectomy
Burr Holes (subdural hematoma)
Orthopedics:
Total Joint Replacement
Arthroscopy
Harrington Rod Insertion
Dwyer Anterior Fusion
I.M. Rodding
Zimmer Hip Compression
Reduction with Compression Sets
Fracture Table Use
Hand Surgery – Including Implants
Gynecology:
Abdominal Hysterectomy
Vaginal Hysterectomy
Laporoscopy
Marshall Marchetti Krantz
Tubopiasty
Cholecystectomy
C-Sections
Pediatrics:
Pediatric Lap
Pediatric Inguinal Hernia
Plloric Stenosis
Bronchoscopy
Opthalmology:
Phaco Emulaification
ICLE
ECLE
Retina
Lid and Muscle Procedures
Enucieation
Plastics:
Augmentation Mammoplasty
Reduction Mammoplasty
Rhinoplasty
Cleft Lip and Plasty Repair
Abdominal Lipectomy
Skin Grafts
Otoplasty 
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