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. Work settingsAmbulatory OR1234CVOR1234First Assist1234General OR1234Labor & Delivery1234Pedi CVOR1234Pedi General OR1234Sterile processing1234Trauma1234BariatricsBiliopancreatic Diversion with Duodenal Switch (BPD/DS)1234Gastric bypass1234Gastric Sleeve1234Lap band1234Laparoscopic assisted cases1234Robotic Assisted Bariatric Cases1234CardiovascularAbdominal Aortic Aneurysm repair1234Atherectomy1234Atrial Septal defect repair1234Cardiomyoplasty1234Carotid endarterectomy1234Coronary Artery Bypass Graft1234Endovascular Aneurysm Repair1234Endovascular Aortic Repair (EVAR)1234Femoral popliteal bypass graft1234Laparoscopic Cardiac Surgery1234Mitral valve replacement1234Pericardial window1234Robotic Assisted Cardiac Surgery1234Transcatheter Aortic Valve Replacement (TAVR)1234Thoracic Endovascular Aortic Repair (TEVAR)1234Ventricular Assist Device (VAD)1234Vein stripping1234Ear, Nose, Throat (ENT)Endoscopic SINUS procedures1234Direct Laryngoscopy1234Septoplasty/Rhinoplasty1234Mastoidectomy/Tympanoplasty/Stapedectomy1234Radical neck dissection1234Tracheostomy1234Scrub ENT Surgery1234Tobotic TORS1234Endoscopic ProceduresBronchoscopy1234Colonoscopy1234EGD1234Peg tube placement/exchange1234Sigmoidoscopy1234General SurgeryAppendectomy1234Breast biopsy1234Cholecystectomy1234Colon resection - Open/LAP1234Hernia repair inguinal/umbilical1234Laparoscopic assisted procedures1234Laparoscopic nissen fundoplication1234Mastectomy1234Robotic assisted procedures1234Thyroidectomy partial/total1234Whipple1234Liver Resection1234Rectal Procedures1234Exploratory Laparotomy1234HIPEC1234GynecologyAbdominal/ Vaginal hysterectomy1234Anterior/Posterior repair1234Bilateral tubal ligation1234C-sections1234Dilation & Curettage1234Laparoscopic assisted gynecological procedures1234Robotic assisted Gynecological procedures1234Tuboplasty1234Vaginal delivery1234Vaginal Hysterectomy1234NeurosurgeryAnterior cervical fusion1234Brain biopsy1234Cervical fusion1234Acoustic Neuroma1234Craniotomy1234Insertion of VP shunt1234Laminectomy/discectomy1234Lumbar fusion1234ALIF1234XLIF1234Kyphoplasty1234MIS1234OphthalmologyCataract extraction/implant1234Corneal transplant1234Eye trauma1234Glaucoma surgery1234Vitrectomy1234OrthopedicAnterior Cruciate Ligament Reconstruction1234Arthroscopy1234Arthrotomy1234Bankhart procedure1234Birmingham procedure1234Carpal tunnel release1234Closed reduction of fractures1234Total Knee Replacement1234Total Hip Replacement1234PlasticsAbdominoplasty1234Blepharoplasty1234Breast reduction1234Breast reconstruction1234Face lift1234Breast augmentation1234Mastectomy with tram flap reconstruction1234Free Flap - Microvascular1234Fat Grafting1234PodiatryAnkle fusion1234Bunionectomy1234Hallux vagus arthroplasty/arthrodesis1234Metatarsal surgery1234ThoracicVATS1234Lung resection- Thoracotomy1234Mediastinoscopy1234Robotic VATS1234Transplant (copy)Corneal1234Heart/Lung1234Kidney1234Liver1234Lung1234Organ donation1234Pancreas1234Skin1234TraumaAmputations1234Burns1234Gunshot/stab wounds1234MVA (multiple injuries)1234UrologyBladder sling1234Circumcision1234Cystectomy1234Cystoscopy1234Laparoscopic assisted cases1234Nephrectomy1234Orchiectomy1234Prostatectomy1234Radical Lymph Node Dissection1234Robotic GU procedures1234Ultrasonic Lithotripsy1234Transurethral resection of the prostate1234Ureteroscopy1234Pediatrics Experience1234Pediatrics Experience1234PEDI BARIATRICSBiliopancreatic Diversion with Duodenal Switch (BPD/DS)1234Gastric bypass1234Gastric Sleeve1234Lap band1234Laparoscopic assisted cases1234Pedi Craniofacial/PlasticsCleft lip/Cleft palate repair1234Crainiectomy1234Mandibular osteotomy1234Otoplasty1234Pharyngoplasty/Pharyngeal Flap Procedure1234Rhinoplasty1234Skin grafts1234PEDI CARDIOVASCULARArterial switch operation1234ASD/VSD repair1234Coarctaction of the aorta repair1234ECMO insertion/decanulation1234Epstein’s Anomaly repair1234Fontan procedure1234Norwood procedure1234PDA ligation1234Tetralogy of Fallot Repair1234Transposition of the Great Arteries repair1234Valve Repair/Replacement1234Ventricular Assist Device Implant1234PEDI EAR/NOSE/THROATCochlear implant1234Frenulectomy1234Myringotomy with tubes1234Septoplasty1234Tonsillectomy/adenoids1234Tracheostomy1234Tympanoplasty1234PEDI EAR/NOSE/THROAT (copy)Bronchoscopy1234EGD1234Flexible sigmoidoscopy1234Peg tube placement/exchange/removal1234PEDI GENERAL SURGERYAnal Fistulectomy1234Appendectomy1234Breast mass excisional biopsy1234Central venous line insertion/removal1234Cholecystectomy1234Circumcision1234Colon resection1234Colostomy closure/reversal1234Epigastric hernia repair1234Excision of Hemangiomas1234Exploratory laparotomy1234Inguinal hernia repair1234Laparoscopic scrub surgery1234Nissen fundoplication1234Splenectomy1234Scrub Pedi General Surgery1234PEDI GYNECOLOGYCongenital anomalies1234Labia reduction1234Labial adhesions1234Pelvic masses1234Vulvar lesion/masses1234Scrub Pedi Gynecology Surgery1234PEDI NEUROLOGYCraniotomy1234Neuroendoscopy for brain/spinal tumors1234Spinal bifida repair1234Vagus nerve stimulator1234VP/VA shunts1234Scrub Pedi Neurology1234PEDI OPHTHAMOLOGYCataract extraction/implant1234Eye muscle surgery1234Eye trauma1234Laparoscopic assisted cases1234Levator resection1234Vitrectomy1234Scrub Pedi Ophthalmology Surgery1234PEDI ORTHOPEDICAnterior Cruciate Ligament Reconstruction1234Arthroscopy of knee, shoulder, wrist1234Arthrotomy1234Closed reduction of fractures1234Open reduction of fractures1234Percutaneous pin1234Spinal fusion/spinal with instrumentation1234Tendoachilles lengthening1234Scrub Pedi Orthopedic Surgery1234PEDI PODIATRYClub foot1234Juvenile bunion1234Labial adhesions1234PEDI TRANSPLANTBone marrow1234Heart1234Kidney1234Liver1234Lung1234Organ donation1234PEDI UROLOGYCircumcision1234Cystoscopy/Cystogram/Pyleogram1234Hydrocele1234Nephrectomy1234Ochiectomy/Orchidopexy1234Repair of Hypospadias1234Ureterostomy1234EMERGENCY MANAGEMENTCode response1234Fire Safety1234Latex Allergy1234Equipment/Instrumentation/SuppliesArthroscopes1234Blood/fluid warmer1234Camera/video systems OR1234Care of scopes & fiber optic equipment1234Cell saver1234Disposable grounding pads1234Drills (multiple types)1234Electrosurgical units1234Endoscopic equipment1234Fiber optic light sources/cords1234Fracture tables1234Intestinal stapling devices1234Laparoscopes1234Patient warming devices1234Robotics (Da Vinci)1234Steris1234Tourniquets1234Vacuum curettage1234Washer/sterilizer1234Professional Knowledge and SkillsElectrosurgical Safety1234Infection Prevention1234Instrument Processing1234Isolation Precautions1234Laser Safety1234Malignant Hyperthermia Protocol1234National Patient Safety Goals/Core Measures1234Radiation Safety1234Specimen Handling/labeling1234Sterilization/Disinfection1234Universal Protocol (Time out) Procedure1234COMPUTERIZED CHARTINGAllscripts1234Cerner1234EPIC1234McKesson1234Other:1234If other, please specifyAge specific competencyNeonate1234Infant1234Child1234Adolescent1234Young Adult1234Middle Adult1234Older Adult1234Submit
