EMERGENCY EXPERIENCE PROFILE

First Name: Last Name:Grad from nursing school:

Degree: RNC N/A PALS N/A
NRP N/A

State of original License:

State of current License:

Phone Number:

Please indicate your level of experience with the following patient groups and clinical skills category according to the number of years of experience indicated below:

CATEGORIES 0, 1, 2, 3

0=No experience
1=limited experience
2=perform with review
3=perform independently

	PATIENT GROUPS	0	1	2	3
	Neonate
	Infant
	Children
	Adolescent
PECIATRIC NURSING
TRAUMA CENTER EXPERIENCE
Level One
Level Two
Level Three
ASSESSMENT SKILLS
Cardiopulmonary
Developmental
Social/abuse
CLINICAL SKILLS
EKG set up & run
EKG interpret
CHF
Acute MI
Thromoblytic-MI
Thromoblytic-CVA
Symptomatic arrhythmias
Cardioversion
Cardiac tamponade
Temporary pacemaker
New onset chest pain
Electropysiology studies
Starting IV's neonate
Starting IV's infant
Starting IV's children
Starting IV's adolescent
Starting IV's adult
Defibrillation
Starting IV's geriatric
Code Blue team leader
Dopamine
Levophed
Nitroglycerine
Lidocaine
Trauma MVA
Trauma GSW
Trauma Stabbing
Trauma Burns
Haz-mat exposure
Trauma-closed head injury
Trauma-spinal cord injury
Drug overdose
Acute CVA
Adult repiratory distress
Infant severe respiratory distress
Oxygen set up & delivery masks
Nebulizers
Intubation performing
Intubation assisting
Ventilator use
SET UP & ASSIST WITH
IV cutdown
Central line placement
ABG draws-A-line
ABG draws-puncture
Chest tube insertion
Thoracentesis
Paracentesis
Sutures/staples
Gastric/lavage
Shock-sepsis
Shock-Anaphyllactic
Shock-hemorrhagic
Burns
Tracheotomy
Bronchoscopy
Proctoscopy
Endoscopy
Laryngoscopy
Casting
Skeletal traction, pin placement
Hypertension
CLINIC PRESENTATIONS
Dog bites
Strep Throat
RSV
Flu
Ear problems
Sports Injuries

EMERGENCY NURSING WORK HISTORY
TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:

Authorization (Please type your name and the date.)

By submitting this application, I hereby certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

Signature Date

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