Experience
A	No Practice
B	Less than one year
C	One - Two years
D	Two Plus Years experience

First Name             Last Name

Abuse Protection Reporting		- A B C D
Advocacy - Patient		- A B C D
Assist -	Patient / resident to ambulate	- A B C D
	A choking conscious patient / resident	- A B C D
Apply -	Knee / thigh length anti-embolism stockings	- A B C D
	Wrist, jacket, waist or bed rail restraint	- A B C D
Cleaning -	Natural teeth	- A B C D
	Dentures	- A B C D
Caring for -	Indwelling catheter	- A B C D
	Urinary drainage apparatus (ostomy)	- A B C D
Dressing a patient / resident		- A B C D
Giving a whirlpool bath ambulatory / non-ambulatory		- A B C D
Hand washing		- A B C D
Giving a complete bath		- A B C D
Measuring -	Oral temperature - electronic thermometer	- A B C D
	Rectal temperature - electronic thermometer	- A B C D
	Maxillary temperature - electronic thermometer	- A B C D
Shaving -	Male / female patient / resident electric razor	- A B C D
	Male / female patient / resident safety razor	- A B C D
Feeding a patient / resident		- A B C D
Measuring -	Apical pulse	- A B C D
	Radial pulse & respiration	- A B C D
	Blood Pressure	- A B C D
	Weight	- A B C D
	Urinary output	- A B C D
Offering, removing	Bedpan	- A B C D
& cleaning -	Urinal	- A B C D
Providing -	Perineal care	- A B C D
	Fingernail care	- A B C D
	Foot care	- A B C D
Turning patient / resident to the side		- A B C D
Measuring radial pulse & respiration		- A B C D
Moving patient / resident to the head of bed-one assist		- A B C D
Giving a backrub		- A B C D
Standard precautions		- A B C D
Making a hospital	Occupied	- A B C D
bed -	Unoccupied	- A B C D
Providing range of	Upper extremities	- A B C D
motion exercises -	Lower extremities	- A B C D
Repositioning of the patient / resident in chair		- A B C D
Transferring patient / resident to/from bed/chair		- A B C D
Giving a shower ambulatory / non-ambulatory patient / resident		- A B C D
Age Experience  -  Select each age group you have expertise in.
Newborn / neonatal birth - 30 days
Infant & toddler 30 days - 3 years
Preschool thru age 12
Adolescents 12 - 18 years
Young adult 19 - 40 years
Middle adults 40 - 65 years
Seniors 65+ years

The information I have provided is true and accurate to the best of my knowledge. I give authorization to Sierra Staffing, Inc. to release this information to facilities in consideration of my employment at said facility.