Please enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastEmail *Phone No experience: requires education, training and supervision Intermittent experience: may need support or supervise Proficient: consistent experience, independent Expert level: can teach/supervise others. BASIC CARE AND ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (copy)1. Baths123452. Shampoo123453. Nail Care123454. Oral Care123455. Routine Skin Care123456. Positioning123457. Back Rubs123458. Ambulation Assistance123459. Oral and Nasal Care for Patients with NG Tube Feedings1234510. Routine Catheter Care for Indwelling and External Catheters12345VITALS AND MEASUREMENTS1. Temperature, Pulse and Respiration Measurements123452. Obtains Blood Pressure Measurements123453. Measure Height and Weight123454. Accurately Maintain Intake, Output and Documents123455. Distinguishes measurements that must be Immediately reported to any of the following: Patient Family/Supervising Nurse/MD/91112345NUTRITIONAL SUPPORT 1. Assists with meals and snacks consistent with treatment plan123452. Feeds patients with normal swallowing abilities123453. Administers gravity tube feedings through existing feeding Tubes within scope of CNA certification12345ELIMINATION SUPPORT 1. Administers enemas as instructed by the supervising nurse or MD123452. Applies condom catheters as instructed by the supervising nurse or MD12345PULMONARY SUPPORT 1. Assist the patient in performing turn, cough and deep breathing exercises consistent with treatment plan123452. Assist the patient in performing incentive spirometry123453. Practices oxygen safety12345COLLECTION OF SPECIMENS FOR LABORATORY ANALYSIS1. Collects routine specimens for laboratory analysis for assigned patients. Voided, clean catch and 24 hour urine123452. Stool123453. Sputum123454. Labels specimens consistent with lab requirements12345FAMILIAR WITH VARIOUS ASSISTIVE DEVICES/TECHNIQUES. 1. Proper body mechanics123452. Transfer from bed to chair123453. Transfer from chair to bed123454. Proper use of Hoyer lifts123455. Proper use of specialty beds.12345EXPERIENCE WITH AGE GROUPS:1. Able to adapt care to incorporate normal growth and development123452. Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level123453. Can ensure a safe environment reflecting specific needs of various age groups.12345AGE SPECIFIC COMPETENCY 1. Newborn/Neonate (Birth to 30 Days)123452. Infant (30 days to 1 Year)123453. Toddler (1 - 3 Years)123454. Preschool Child (3 - 5 Years123455. School Age Child (5 - 12 Years)123456. Adolescent (12 - 18 Years)123457. Young Adult (18 - 39 Years)123458. Middle Age Adult (40 - 65 Years)123459. Senior Adult (65+ Years)12345Submit
