OPERATING ROOM & RECOVERY EXPERIENCE PROFILE

First Name: Last Name:Grad from nursing school:

Degree: CNOR N/A RN,C N/A

ACLS 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
	Adult
	Geriatric
SUGERY/RECOVERY SKILLS
Recovery only
Circulate only
Scrub only
Scrub & Circulate
Circulate & recovery
Cataract removal w/lens implant
Corneal transplant
Enucleation
Foreign body removal
Retina attachment
Muscle repair
Blepharoplasty
Sinus repair
Tracheostomy
Septoplasty
Tympanoplasty
T & A
Radical neck dissection
Maxillary procedures
Cleft lip/palate
Rhinoplasty
Gunshot wounds
Laparotomy
Laparoscopy
Appendectomy
Colon resection
Adb resection
Open cholescystectomy
Endo/lap cholecystectomy
Open/lap chole with grams
Herniorrhaphy
Thyroidectomy
Mastectomy (Modified & radical)
Abdominal hysterectomy
Vaginal hysterectomy
Tubal ligation
Vaginal A&P repair
Cesarean section
Prostatectomy
Hemorrhoidectomy
Total joint replacements, knee
Total joint replacement, hip
Rotator cuff
Open fracture reduction
Open reduction w/internal fixation
Closed fracture reduction
Amputation
Arthroscopy
Ligament repair (knee)
Carpal tunnel repair
Cervical laminectomy
Lumbar laminectomy
VP shunt placement
Acoustic neuroma
Craniotomy
Craniotomy with tumor excision
Bunionectomy
Hand surgery
Bariactric surgery
Abdominoplasty
Mammoplasty
Breast augmentation
Breast reduction
Cystoscopy
T.U.R.P.
Orchiectomy
Nephrectomy
Ileal conduit/suprapubic catheter
Laser-eye
Laser-endo
Laser-cosmetic
Laser-plastic
Laser-orthopedic

CARDIOVASCULAR
CABG
Angioplasty
Abd aortic aneurysm
Femoral bypass
Embolectomy
Vein ligation
Carotid endarterectomy
Valve replacement
Pacemaker/defibrillator placement
Pneumonectomy
Atrial-Septum defect
Ventricular septum defect
Infusaport placement
Greenfield filter placement
Infant abdominal procedures
Infant open heart procedures
Neonatal procedures

OPERATING ROOM & RECOVERY 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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