Forms

Applicant Forms

Please fill out applicable forms completely in order to complete your employment assessments and application.

RN L&D Form





  • 0 = Not Applicable
    1 = No Experience
    2 = Some Experience
    3 = Intermittent Experience
    4 = Experience
    5 = Very Experience

    *Required Fields


  • 0 1 2 3 4 5
    Newborn/Neonate (Birth to 30 days)*
    Infant (1 month to 1 year)*
    Toddler (1 year to 3 years)*
    Preschooler (3 years to 5 years)*
    School Age Child (5 years to 12 years)*
    Adolescents (12 years to 18 years)*
    Young Adults (18 years to 39 years)*
    Middle Adults (39 years to 64 years)*
    Older Adults (64 years to 79 years)*
    Elderly Adults (over 79+ years)*

  • 0 1 2 3 4 5
    Patient and Family Teaching*
    Coaching Needs*
    Universal Precautions*
    Isolation Precautions*
    Care of the Patient in restraints*
    Cardiac Monitoring*
    Pulse Oximetry*
    Ventilator Management (Adult)*
    Ventilator Management (Newborn)*
    Prep and Administration of Emergency Meds*
    Infant/ Neonatal Cardiac/ Respiratory Arrest*
    Adult Cardiac/ Respiratory Arrest*
    End of Life Care*
    Fetal Monitoring- Basic*
    Fetal Monitoring- Advanced*
    IV Therapy*
    Administration of Blood/ Blood Products.*
    Knowledge of Normal Lab Values*
    Newborn*
    Labor Patient*
    Pain Management*
    Automated Med Dispensing System*
    List Types:
    Automated Med Dispensing System
    List Types:
    Electronic Documentation*
    List Types:
    CARE OF PATIENTS WITH PRE-EXISTING CONDITIONS/ HIGH
    Cardiac Disease*
    Neurological Disease*
    Seizure Disorder*
    Chronic Diabetes Mellitus*
    Pregnancy Induced Diabetes Mellitus*
    Asthma*
    Chronic Hypertension*
    Pregnancy- Induced Hypertension*
    Infectious Disease*
    HBV*
    HIV*
    Sickle Cell Disease*
    RH Incompatibilities*
    Hemolytic Anemia*
    Collagen Vascular Disease*
    Hemorrhage*
    Drug Addiction/ Withdrawal*
    Pyelonephritis*
    Abruptio Placenta*
    Placenta Previa*
    Placenta Acreta*
    Preeclampsia*
    Eclampsia*
    Premature Labor*
    Malpresentations*
    Breech*
    Transverse Lie/ Shoulder*
    Face Presentation*
    Brow Presentation*
    Multiple Gestation*
    PROM*
    Chorioamnionitis*
    Poly/ Oligohydramnios*
    Prior Tubal Ligation*
    VBAC Management/ Trial of Labor*
    Uterine Rupture*
    Incompetent Cervex (Shirodkar Suture/ Cerclage)*
    Spontaneous Abortions- Complete/ Incomplete*
    Intrauterine Growth Retardation (IUGR)*
    Postdate Pregnancy*
    HELLP Syndrome*
    DIC*
    Fetal Demise*

  • 0 1 2 3 4 5
    Cardiac Disease*
    Neurological Disease*
    Seizure Disorder*
    Chronic Diabetes Mellitus*
    Pregnancy Induced Diabetes Mellitus*
    Asthma*
    Chronic Hypertension*
    Pregnancy- Induced Hypertension*
    Infectious Disease*
    HBV*
    HIV*
    Sickle Cell Disease*
    RH Incompatibilities*
    Hemolytic Anemia*
    Collagen Vascular Disease*
    Hemorrhage*
    Drug Addiction/ Withdrawal*
    Pyelonephritis*
    Abruptio Placenta*
    Placenta Previa*
    Placenta Acreta*
    Preeclampsia*
    Eclampsia*
    Premature Labor*
    Malpresentations*
    Breech*
    Transverse Lie/ Shoulder*
    Face Presentation*
    Brow Presentation*
    Multiple Gestation*
    PROM*
    Chorioamnionitis*
    Poly/ Oligohydramnios*
    Prior Tubal Ligation*
    VBAC Management/ Trial of Labor*
    Uterine Rupture*
    Incompetent Cervex (Shirodkar Suture/ Cerclage)*
    Spontaneous Abortions- Complete/ Incomplete*
    Intrauterine Growth Retardation (IUGR)*
    Postdate Pregnancy*
    HELLP Syndrome*
    DIC*
    Fetal Demise*

  • 0 1 2 3 4 5
    Triage of Obstetrical Patients*
    Assessment of Birth Plan*
    Perform Admission Risk Assessment*
    Non- Stress Test (NST)*
    Induction of Labor*
    Oxytocin Challenge Tests (OCT)*
    Biophysical Profile*
    Assist with Sonogram*
    Perform Sonogram*
    Assist with Amniocentesis*
    Normal Perinatal Vital Signs*
    Deep Tendon Reflex Checks (DTR’s)*
    Edema Assessment*
    Clonus*
    Assess for Comfort*
    Breathing/ Relaxation Techniques*
    Coaching*
    Positioning*

  • 0 1 2 3 4 5
    Ritodrine*
    Magnesium Sulfate*
    Terbutaline*
    Indomethacin*
    Procardia*
    Pitocin*
    Oxytocin*
    Cervidil*
    Cytotec*
    Prostin Suppositories*
    Assist with Prostin Gel*
    Antibiotics*
    Antihypertensives*
    Heparin*
    Stadol*
    Nubain*
    Morphine*
    Demerol*
    Fentanyl*
    Insulin Drips*
    Insulin Pumps*
    Insulin SC*
    AZT/ Other Antiviral Medications*
    Rhogam*

  • 0 1 2 3 4 5
    Starting PIV’s*
    PICC Lines- Care and Maintenance*
    Central Venous Lines- Care and Maintenance*
    Invasive Hemodynamic Monitoring*
    Blood Draw from PICC/ CVL*
    Administration of Blood/ Blood Products*
    IV Infusion Pumps*
    Blood/ Fluid Warmers*

  • 0 1 2 3 4 5
    Normal Vital Signs- Baseline*
    Identify Common Cardiac Arrhythmias*
    Assist with Sterile Speculum Exam*
    Perform Sterile Speculum Exam*
    Vaginal Exam- Manual*
    Status of Membranes*
    Assist with Rupture of Membranes*
    Fern Test*
    Nitrazine*
    Presence of Clonus*
    DTR’s*
    Edema*
    Progression Of Labor*
    Dilation*
    Effacement*
    Fetal Position*
    Fetal Presentation*
    Station*
    Contraction Characteristics*
    Determination of Fetal Head Position*
    Documentation of Labor Status and Interventions*
    Labor Suppressants*
    Collection of Blood Specimens*
    Collect Urine Specimens*
    Toxicology Studies*
    Collect Vaginal Cultures*
    Fluid*
    Herpes*
    Chlamydia*
    Group B Strep*
    Perform Leopold’s Maneuvers*
    Amnioinfusion (assist or perform) for:
    Variable Decelerations*
    Meconium*
    Prolapsed Cord*
    Vasa Previa*
    Catheter Insertion Straight Cath*
    Foley*

  • 0 1 2 3 4 5
    Fetal Heart Rate- Doppler*
    Fetal Heart Rate- Auscultate*
    Document Fetal Position*
    Fetal Heart Rate Patterns: Identify & Treat Baseline
    Variability*
    Variable Decelerations* ntrauterine Pressure Catheter (IUPC) Placement*
    Early Decelerations*
    Late Decelerations*
    Prolonged Decelerations*
    External Fetal Monitor Application*
    Internal Fetal Monitor Application (Assist)*
    Internal Fetal Monitor Application (Perform)*
    Spiral Electrode*
    Intrauterine Pressure Catheter (IUPC) Placement*
    Calibration*
    Fluid Filled*
    Transducer Tipped*

  • 0 1 2 3 4 5
    Assist with Vaginal Delivery*
    Forceps Extraction*
    Vacuum Extraction*
    Assist with High Risk Delivery*
    Shoulder Dystocia* Hemorrhage/ Shock*
    Emergency Delivery*
    Abdominal Shave/ Scrub Prep*
    Perineal Prep*
    Circulate for C-Section*
    Scrub for C-Section*
    Patient with General Anesthesia*
    Patient with Epidural Anesthesia*
    Circulate with Tubal Ligation*
    Scrub for Tubal Ligation*
    Assist with Placenta Delivery*
    Fundus Massage*
    Assist with Cervical Laceration Repair*
    Assist with Uterine Laceration Repair*
    Assist with Episiotomy Repair*

  • 0 1 2 3 4 5
    Newborn Assessment Ballard*
    Dubowitz*
    Finnegan/ Abstinence Scoring*
    Apgar Scores*
    Initial Vital Signs*
    Bulb Suctioning*
    Delee Suctioning*
    Wall Suctioning*
    Meconium Aspiration*
    Collect Cord Samples*
    Assist with UAC/ UVC Insertion*
    Insertion of IV, Including Scalp IV*
    Radiant Warmer/ Thermoregulation*
    Interventions for LGA, SGA, IUGR*
    Interventions for Infant of Diabetic Mother*
    Oxygen Administration*
    Bag/ Mask Ventilation of the Newborn*
    Assist with Intubation*
    Transport Isolette*
    Heelstick Glucose*
    Eye Prophylaxis*
    Vitamin K*
    ID/ Security Banding*
    Promote Bonding Behaviors*
    Lead Placement for Cardiac Monitor*
    Apnea Monitoring*
    Oxyhood*

  • 0 1 2 3 4 5
    Fundal Height*
    Fundal Massage* Lochia*
    Episiotomy Care*
    Perineum Care*
    Maternal Vital Signs*
    Recovering Post-Op C-Section Patients*
    Recovering Post-Op Tubal Ligation Patient*
    Fluid Balance*
    Assessment for DVT*
    Couplet Care*
    Breast Care*
    Breastfeeding*
    Assists in plans and goals for lactation services

  • 0 1 2 3 4 5
    Cord Care*
    Circumcision Care*
    Bath Demonstration*
    Assist with Lumbar Puncture*
    Administration of IV Antibiotics*
    Newborn Vital Signs*
    Assist with Breastfeeding Latch On*
    Positioning*

  • 0 1 2 3 4 5
    Cardiac Anomalies*
    Drug Addiction/ Withdrawal*
    Cystic Fibrosis*
    Meconium Aspiration*
    Pneumonia*
    Pulmonary Edema* RDS*
    NEC*
    Neuromuscular Disease*
    Spina Bifida*
    Seizure Activity*
    Tracheoesophageal Fistula*
    Sepsis*
    Sickle Cell Disease*
    Low Birth Weight Infants*

  • 0 1 2 3 4 5
    Assess Pain Level*
    Assess Acceptable Level of Pain*
    Intranasal Pain Medications*
    Oral Pain Medications*
    IV Pain Medications*
    PCA*
    IV Conscious Sedation*
    Epidural Pain Management*
    Intervention for Anesthesia Toxicity*
    Assist with Epidural Insertion Positioning of Patient*
    Signs of Dural Puncture*
    Fluid Challenge*
    Hypotension*
    Intrathecal Narcotics*
  • My experience is mostly in…(list number of years in each setting)

  • Application Agreement

  • I certify that the information provided above accurately reflects education received and my experience in each of the clinical areas identified within the last 2 years.
    The information I have given is true and accurate to the best of my knowledge, and I hereby authorize Royalty Medical Solutions Inc to submit this skills evaluation to their clients. To be updated annually.


  • Date Format: MM slash DD slash YYYY

















Medical Assistant Skills Checklist





  • 0 = Not Applicable
    1 = No Experience
    2 = Some Experience
    3 = Intermittent Experience
    4 = Experience
    5 = Very Experience

    *Required Fields


  • 0 1 2 3 4 5
    Newborn (Birth to 30 days)*
    Infant (1 month to 1 year)*
    Toddler (1 year to 3 years)*
    Preschooler (3 years to 5 years)*
    School Age Child (5 years to 12 years)*
    Adolescents (12 years to 18 years)*
    Young Adults (18 years to 39 years)*
    Middle Adults (39 years to 64 years)*
    Older Adults (64 years to 79 years)*
    Elderly Adults (over 79+ years)*

  • 0 1 2 3 4 5
    Gynecology
    Family Practice
    Obstetrics
    Oncology
    Orthopedics
    Pediatrics
    Post Portum
    Renal/dialysis
    Outpatient clinic

  • 0 1 2 3 4 5
    Transcribing
    Taking Patient’s History
    Ability to perform spirometry
    Ability to perform EKG
    Ability to use a centrifuge
    Ability to use a Stethoscope
    Nebulizer
    Vitals: Pulse oximeter, Blood Pressure, Tempature
    Oxygen

  • 0 1 2 3 4 5
    Phlebotomy: venipuncture
    Urinalysis
    Collection of Specimen
    Stool Collection
    Vision Testing
    Pregnancy Test
    Vaginal Swabs
    Wound Swabs
    Throat Swabs
    Hearing Screening
    Other: List
  • I certify that the information provided above accurately reflects education received and my experience in each of the clinical areas identified within the last 2 years.
    I hereby release this self assessment of skills to clients of Royalty Medical Solutions.






  • Date Format: MM slash DD slash YYYY