Forms

Applicant Forms

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

RN L&D Form

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

  *Required Fields

• AGE OF PATIENT CARED FOR*
  

  	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)*

• GENERAL SKILLS*
  

  	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*

• CARE OF PATIENTS WITH PRE-EXISTING CONDITIONS/ HIGH*
  

  	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*

• ANTEPARTUM*
  

  	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*

• MEDICATIONS*
  

  	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*

• IV THERAPY/ PROCEDURES*
  

  	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*

• LABOR ASSESSMENT/ PROCEDURES: MATERNAL:*
  

  	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*

• LABOR ASSESSMENT/ PROCEDURES: FETAL:*
  

  	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*

• DELIVERY/ C-SECTION*
  

  	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*

• IMMEDIATE CARE OF NEWBORN IN DELIVERY ROOM*
  

  	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*

• POSTPARTUM CARE*
  

  	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

• NEWBORN CARE*
  

  	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*

• CARE OF THE INFANT WITH*
  

  	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*

• PAIN MANAGEMENT/ANESTHESIA*
  

  	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*

• List any Additional Training:
• List any Additional Skills:
• List Any Additional Equipment:
• Experience with ventilators?***
  • Yes
  • No
• Experience with cardiac monitors?***
  • Yes
  • No
• NRP current?**
  • Yes
  • No
• STABLE current?**
  • Yes
  • No
• Fetal monitoring course – basic?**
  • Yes
  • No
• Fetal monitoring course – intermediate?**
  • Yes
  • No
• Fetal monitoring course – advanced?**
  • Yes
  • No

• My experience is mostly in…(list number of years in each setting)

• Labor and Delivery*1234568910+
• LDR:**1234568910+
• LDRP:**1234568910+
• Community Hospital (Also list number of births per month):**1234568910+
• Number of deliveries per month (average in last year):**1234568910+
• Have you ever experience an unattended delivery:**YesNo

• 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.
• Signature
• Date
  
  Date Format: MM slash DD slash YYYY
  
• Name
  
  First
  
  Last
• Specialty Lactation Consultant
  
  First
  
  Last
• Applicant Email
  
• Applicant Phone

Medical Assistant Skills Checklist

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

  *Required Fields

• AGE*
  

  	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)*

• Specialty Experience*
  

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

• Back Office Skills*
  

  	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

• Labs:*
  

  	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

• List any Additional Labs:
• 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.
• Name
  
  First
  
  Last
• Signature
• Date
  
  Date Format: MM slash DD slash YYYY