SELF EVALUATION
POLYSOMNOGRAPHY 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:

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

LEVELS OF PROFICIENCY KEY:
 HP = Highly Proficient; Extensively experienced; able to supervise and/or train others.
VE = Very Experienced; can perform well, without assistance or supervision.
EX = Experienced; competent; can perform independently; may need initial review or supervision.
 SE = Some Experience; need review and assistance or supervision.
NE = No Experience.

PROFICIENCY LEVEL
PATIENT PREPARATION: HP VE EX SE NE
Standard 10-20 Hook-up
Full Head Hook-up
Seizure Hook-up
Patient Pre-study Calibration
Patient CPAP/BIPAP Trials
ROUTINE SLEEP STUDIES: HP VE EX SE NE
Baseline Polysomnogram
without CPAP/BIPAP
Split-night Polysomnogram
with CPAP/BIPAP
Full Night Polysomnogram
with CPAP/BIPAP Titration
Newborn Polysomnogram
with or without CPAP/BIPAP
Infant Polysomnogram
with or without CPAP/BIPAP
Restless Legs Syndrome
Periodic Leg Movement
SAO2 and CO2 Monitors
Breathing Abnormalities
EQUIPMENT USAGE: HP VE EX SE NE
Grass
Sandman
Sensormedics
Alice 3
NCI
Nihon Koden Analog
Teca
Nicolet
Biologic
Digitrace
Other, please list:
DAYTIME STUDIES: HP VE EX SE NE
Wake Study
Multiple Sleep Latency Test (MSLT)
SPECIAL STUDIES AND PROCEDURES: HP VE EX SE NE
Seizure Study
Esophageal Pressure Tube Insertion
Night Terror Study
Study of Sleep Walking
Nocturnal Penile Tumescence (NPT)
Hypnogogic Hallucinations
Headache (Migraine, Cluster, etc.)
Research Studies
(alcohol, drugs, safety, driving, etc.)
Insomnia
Data Scoring
SYSTEMS EXPERIENCE: HP VE EX SE NE
100% Digital
Paper (graph)
Combined Paper and Digital
Windows-based Software
DOS-based Software
   REGISTRY/LICENSURE:
   RPSGT (Registered Polysomnographer)
   EEG (Electro-Encephalographic Technician)
   CRTT (Certified Respiratory Therapist Technician)
   RRT (Registered Respiratory Therapist)
   Other:
   QUALIFICATIONS:
   BCLS/CPR
   ACLS
   Other:
   Other:
   Other: 
Date:           
© Rapid Temps, Inc., rev 12-99
 
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