CRNA SKILLS EVALUATION
CRNA SKILLS EVALUATION
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Personal Information
Name
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First
Last
Title / Specialty
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Email
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Phone
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General Anesthesia and Analgesia
Inhalation Agents
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Intravascular Agents
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Intravenous Agents
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Pre-Operative Prep. & Medication
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1
Other 1 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 2
Other 2 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Regional Anesthesia
Epidural and Caudel
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Field Blocks
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Infiltration
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Intravenous
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Lower Extremity Blocks
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other Peripheral Blocks
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Spinal
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Topical
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Upper Extremity
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1
Other 1 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 2
Other 2 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Procedures - Intravenous Administration of:
Blood
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Cardiac Drugs
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Fluids
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Muscle Relaxants
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Plasma
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Plasma Expanders
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Vasoactive Drugs
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1
Other 1 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 2
Other 2 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 2
ALCS Certifications:
Autotransfusion Techniques
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Cardiopulmonary Bypass Techniques
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Hypotensive and Hypertensive Techniques
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Hypothermia
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Intravenous Catheter Placement
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Mechanical Ventilation
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Placement of Arterial Lines
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Placement of Central Venous Lines
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Placement of Right Heart and Pulmonary Lines
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Resuscitation Techniques & Therapy
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1
Other 1 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 2
Other 2 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Diagnosis and Therapeutic Blocks
Epidural
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Spinal - Differential
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Steroid, Alcohol & Drug Phenol Blocks
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Sympathetic Blocks
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1
Other 1 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 2
Other 2 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Specialties or Specific Skills
OB
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Open Heart
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Pain Management
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Peds
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Other 1
Other 2
Other 2 Experience
Extremely Proficient
Perform Well
Limited Experience
Theory (No Practice)
No Experience
Additional Information
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