Name: (First, MI, Last)* Email Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledGENERAL SURGERY: SCRUBAppendectomy* 0 1 2 3 Breast Biopsy* 0 1 2 3 Cholecystectomy* 0 1 2 3 Abdominal- Perineal Resection* 0 1 2 3 Bowel/Colen Resection* 0 1 2 3 Hernia Repair* 0 1 2 3 Thyroidectomy* 0 1 2 3 Vein Stripping* 0 1 2 3 Radical Mastectomy* 0 1 2 3 Tracheostomy* 0 1 2 3 Gastrectomy* 0 1 2 3 Hickman/Groshong/Portacath Insertion* 0 1 2 3 Cholecytectomy* 0 1 2 3 Bowel* 0 1 2 3 Nissen* 0 1 2 3 Bariatric* 0 1 2 3 THORACIC/CV: CIRCULATEAbdominal Aortic Aneurysm* 0 1 2 3 Aortic- Femoreal Bypass Graft* 0 1 2 3 AV Shaunt / Graft* 0 1 2 3 Carotid Endarterectomy* 0 1 2 3 Lobectomy* 0 1 2 3 Mediastinoscopy* 0 1 2 3 Thoracoscopy* 0 1 2 3 Thoracotomy* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledTHORACIC /CV:S SCRUBAbdomnal Aortic Aneurysm* 0 1 2 3 Aortic - Femoral Bypass Graft* 0 1 2 3 AV Shunt / Graft* 0 1 2 3 Carotid Endarterectomy* 0 1 2 3 Lobectomy* 0 1 2 3 Mediastinoscopy* 0 1 2 3 Thoracoscopy* 0 1 2 3 Thoracotomy* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledORTHOPEDIC/PODIATRY: CIRCULATEKnee Arthoroscopy* 0 1 2 3 ACL Repair* 0 1 2 3 Shoulder Arthroscopy* 0 1 2 3 Endoscopic Shoulder Repair* 0 1 2 3 Open Shoulder Repair* 0 1 2 3 Total Knee Replacement/ Revision* 0 1 2 3 Total Hip Replacement/ Revision* 0 1 2 3 Bipolar Hip Replacement* 0 1 2 3 Hip Compression Nails and Lag screw* 0 1 2 3 Hand Surgery* 0 1 2 3 Extenal Fixation Devices* 0 1 2 3 IM Roddings* 0 1 2 3 Bunionectomy* 0 1 2 3 Spinal Fusion With Instrumentation* 0 1 2 3 Harrington Rod Insertion* 0 1 2 3 Carpal Tunnel Repair* 0 1 2 3 Chick Fracture Table* 0 1 2 3 ORIF With Compression Set* 0 1 2 3 Closed Reduction Fracture* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledORTHOPEDIC/PODIATRY: SCRUBKnee Arthoroscopy* 0 1 2 3 ACL Repair* 0 1 2 3 Shoulder Arthroscopy* 0 1 2 3 Endoscopic Shoulder Repair* 0 1 2 3 Open Shoulder Repair* 0 1 2 3 Total Knee Replacement/ Revision* 0 1 2 3 Total Hip Replacement/ Revision* 0 1 2 3 Bipolar Hip Replacement* 0 1 2 3 Hip Compression Nails and Lag screw* 0 1 2 3 Hand Surgery* 0 1 2 3 Extenal Fixation Devices* 0 1 2 3 IM Roddings* 0 1 2 3 Bunionectomy* 0 1 2 3 Spinal Fusion With Instrumentation* 0 1 2 3 Harrington Rod Insertion* 0 1 2 3 Carpal Tunnel Repair* 0 1 2 3 Chick Fracture Table* 0 1 2 3 ORIF With Compression Set* 0 1 2 3 Closed Reduction Fracture* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledNeurosurgery: CirculateCervical Laminectomy (Anterior)* 0 1 2 3 Cervical Laminectomy (Posterior)* 0 1 2 3 Lumbar Laminectomy* 0 1 2 3 VP Shunt (Ventricular - Peitoneal)* 0 1 2 3 Craniotomy* 0 1 2 3 Burr Holes (Sun- Dural Hematoma)* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledNeurosurgery: ScrubCervical Laminectomy (Anterior)* 0 1 2 3 Cervical Laminectomy (Posterior)* 0 1 2 3 Lumbar Laminectomy* 0 1 2 3 VP Shunt (Ventricular - Peitoneal)* 0 1 2 3 Craniotomy* 0 1 2 3 Burr Holes (Sun- Dural Hematoma)* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledPlastic/ Reconstructive Surgery: CirculateAbdominoplasty* 0 1 2 3 Facelift* 0 1 2 3 Skin Grafts* 0 1 2 3 Breast Reconstruction* 0 1 2 3 Breast Augmentation* 0 1 2 3 Breast Reduction* 0 1 2 3 Rhinoplasty* 0 1 2 3 Cleft Palate Repair* 0 1 2 3 Liposuction* 0 1 2 3 Blepharoplasty* 0 1 2 3 Tissue Expanders* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledPlastic/ Reconstructive Surgery: ScrubAbdominoplasty* 0 1 2 3 Facelift* 0 1 2 3 Skin Grafts* 0 1 2 3 Breast Reconstruction* 0 1 2 3 Breast Augmentation* 0 1 2 3 Breast Reduction* 0 1 2 3 Rhinoplasty* 0 1 2 3 Cleft Palate Repair* 0 1 2 3 Liposuction* 0 1 2 3 Blepharoplasty* 0 1 2 3 Tissue Expanders* 0 1 2 3 Opthalmology: CirculateCataract Extraction with IOL* 0 1 2 3 Corneal Transplant* 0 1 2 3 Dacryocystectomy* 0 1 2 3 Phaco Emulsification* 0 1 2 3 Orbital Implant* 0 1 2 3 Enucleation* 0 1 2 3 Vitrectomy* 0 1 2 3 Scleral Buckle* 0 1 2 3 Muscle Procedures* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledOpthalmology: ScrubCataract Extinction with IOL* 0 1 2 3 Corneal Transplant* 0 1 2 3 Dacryocystectomy* 0 1 2 3 Phaco Emulsification* 0 1 2 3 Orbital Implant* 0 1 2 3 Enucleation* 0 1 2 3 Vitrectomy* 0 1 2 3 Scleral Buckle* 0 1 2 3 Muscle Procedures* 0 1 2 3 Please Use The Following Key: 0 = Never Performed 1 = Partially Skilled 2 = Moderately Skilled 3 = Well SkilledENT/ ORAL SURGERY: CIRCULATEBronchoscopy* 0 1 2 3 T&A* 0 1 2 3 Myringotomy* 0 1 2 3 Stapedectomy* 0 1 2 3 Tympanoplasty* 0 1 2 3 Sinus Endoscopy* 0 1 2 3 Septoplasty* 0 1 2 3 Protidectomy* 0 1 2 3 TMJ* 0 1 2 3 Jaw Fractures* 0 1 2 3 Mini AO Compression* 0 1 2 3 ENT/ORAL SURGERY: SCRUBBronchoscopy* 0 1 2 3 T&A* 0 1 2 3 Myringotomy* 0 1 2 3 Stapedectomy* 0 1 2 3 Tympanoplasty* 0 1 2 3 Sinus Endoscopy* 0 1 2 3 Septoplasty* 0 1 2 3 Protidectomy* 0 1 2 3 TMJ* 0 1 2 3 Jaw Fractures* 0 1 2 3 Mini AO Compression* 0 1 2 3 UROLOGY AND CYSTO: CIRCULATENephrectomy* 0 1 2 3 Prostatectomy* 0 1 2 3 Vasectomy* 0 1 2 3 Cystectomy* 0 1 2 3 Penile Prosthesis* 0 1 2 3 TURP* 0 1 2 3 Cystoscopy/ Ureteroscopy* 0 1 2 3 Lithotripsy* 0 1 2 3 Hypospadias Repair* 0 1 2 3 Orchiopexy* 0 1 2 3 UROLOGY AND CYSTO: SCRUBNephrectomy* 0 1 2 3 Prostatectomy* 0 1 2 3 Vasectomy* 0 1 2 3 Cystectomy* 0 1 2 3 Penile Prosthesis* 0 1 2 3 TURP* 0 1 2 3 Cystoscopy/ Ureteroscopy* 0 1 2 3 Lithotripsy* 0 1 2 3 Hypospadias Repair* 0 1 2 3 Orchiopexy* 0 1 2 3 GYN SURGERY: CIRCULATEAP Repair ( Anterior And Posterior)* 0 1 2 3 D&C* 0 1 2 3 LEEP (Loop Electrode Excision Repair)* 0 1 2 3 Abdominal Hysterectomy* 0 1 2 3 Vaginal Hysterectomy* 0 1 2 3 Laparoscopy* 0 1 2 3 Laparoscopic Tubal Ligation* 0 1 2 3 BLS MM slash DD slash YYYY ACLS MM slash DD slash YYYY Telemetry Certificate MM slash DD slash YYYY ONS Chemo/Biotherapy Certification MM slash DD slash YYYY Other Chemo Certification MM slash DD slash YYYY Areas of Expertise:Consent* By submitting this form, I agree to all terms and conditions and agree to authorize consent CommentsThis field is for validation purposes and should be left unchanged.
