Oncology Skills Checklist: Name - Date
Oncology Skills Checklist: Name - Date
Oncology Skills Checklist: Name - Date
Name___________ ____________________
Date_________ _______________________
Key: 1 = No Experience
2 = Some Experience
3 = Moderate Experience
4 = Proficient
g. Thrombocytopenia b. CADD
Please check the box/es below for each group in which you have provided age-
appropriate care:
A. Newborn/Neonate F. Adolescents (12-18
(birth-30days) years)
G. Young adults (18-39
B. Infant (30 days-1 year)
years)
H. Middle adults (39-64
C. Toddler (1-3 years)
years)
D. Preschooler (3-5 I. Older adults (64-79
years) years)
E. School age children (5- J. Elderly adults (80+
12 years) years)
The information I have provided is true and accurate to the best of my knowledge. I authorize MedCall NorthWest,Inc. to release this Skills Checklist to
. client hospitals as needed in relation to my employment.
Please enter your full legal name as it appears on your Social Security Card.
Email: Month/year Oncology skills were last used: /
* Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on
this document, you are signing the Document electronically. You agree your electronic signature is the legal
equivalent of your manual signature on the Agreement
Name: __________________________________________
ONCOLOGY SKILLS CHECKLIST
Please enter your full legal name as it appears on your Social Security Card.
Email: Month/year Oncology skills were last used: /
* Electronic Signature Agreement. By signing and typing the last 4 of your Social Security Number (SSN) on
this document, you are signing the Document electronically. You agree your electronic signature is the legal
equivalent of your manual signature on the Agreement