PPR Healthcare Staffing, Inc.
333 1st. St. North -- Suite 200
Jacksonville Beach, FL 32250
Fax:(888)794-5038

OPERATING ROOM SKILLS CHECKLIST
Name:   Date:  
Instructions: Use the following Answer Key to indicate the extent of your previous experience:
Key - for each box mark:   1 - Limited or no experience, 2 - Somewhat experienced but may need review,
    3 - Can function independently, 4 - Competent to supervise

      Circulate       Scrub       Assist
Procedures 1     2     3     4   1     2     3     4   1     2     3     4
Cardiovascular          
    Aorto-Femoral Bypass, Graft Insertion    
    A-V Shunts    
    Aneurysms with Graft Replacement    
    Cardiac Valve Replacement    
    Coronary Artery Bypass Graft    
    Endarterectomy - Carotid/Femoral    
    External Temporary Pacemaker    
    Groshong/Hickman Vascular Catheter    
    Internal Pacemaker Insertion    
    Intra-Aortic Balloon Pump Catheter    
    Saphenous Vein Ligation and Stripping    
    Thrombectomy    
Dental/Oral-Facial          
    Arch Bars    
    Closed Reduction Facial Fractures/Wiring    
    Fractured Jaw, Mandibular and Zagomatic    
    Mandibular Osteotomy    
    Maxillary Procedure with Graft    
    TMJ with Arthoplasty    
Endoscopy          
    Bronchoscopy    
    Colonoscopy    
    Cytoscopy    
    Gastroscopy    
    Laryngoscope    
    Sigmoidoscopy    
    Thoracoscopy    
Ear/Nose/Throat          
    Antral Windows    
    Closed Reduction Facial/Nasal Fx    
    Ethmoidectomy    

Page
2
      Circulate       Scrub       Assist
Ear/Nose/Throat continued 1     2     3     4   1     2     3     4   1     2     3     4
    Laryngectomy    
    Mandibulectomy    
    Mastoidectomy    
    Nasal Polypectomy    
    Open Reduction Facial/Nasal Fx    
    Radical Neck Dissection    
    Septoplasty/Rhinoplasty    
    Tracheostomy    
    Tympanoplasty    
Eye          
    Cataract Extraction    
    Corneal Transplant    
    Enucleation    
    Fenestration Procedure    
    Lacrimal Duct Probing    
    Orbital Implant    
    Repair of Retinal Detachment    
General          
    Abdominal Perineal Resection    
    Bowel Resection    
    Cholecystectomy    
    Colostomy/Ileostomy    
    Gastrectomy    
    Herniorrhaphy-Feneral/Inguinal    
    Hiatal Herniorrhaphy Transabdominal    
    Pilonidal Cystectomy    
    Organ Procurement    
    Radical Mastectomy    
    Sentinel Node Biopsy    
    Splenectomy    
    Thyroidectomy    
    Tracheostomy    
Genitourinary/Cystoscopy          
    Cystoscopy/Cystostomy    
    Lithotripsy    
    Nephrectomy    
    Penile Implant    
    Prostatectomy    
    TURP/TURB    
    Ureterolithotomy    
    Vasectomy    

Page
3
      Circulate       Scrub       Assist
Gynecology          
    Caesarean Section    
    Dilation and Curettage    
    Hysterectomy - Abdominal    
    Hysterectomy - Vaginal    
    Ovarian Cystectomy    
    Radium Implant    
    Salpingo-Oophorectomy    
    Suction Curettage    
    Termination of Pregnancy    
    Tubal Ligation    
    Vaginal Reconstruction    
Laparoscopy          
    Appendectomy    
    Cholecystectomy/Cholangiogram    
    Colon Resection    
    Hernia Repair    
    Salpingo-Oophorectomy    
    Tubal Ligation    
    Vaginal Hysterectomy    
Neurology          
    Cervical Fusion    
    Lumbar Interbody Fusion    
    Burr Holes for Subdural Hematoma    
    Carotid Ligation    
    Craniotoplasty/Craniotomy    
    Discectomy    
    Insertion Nerve Stimulators/Medication Pumps    
    Shunts          
      Lumbar Peritoneal    
      Ventricular Atrial    
      Ventricular Peritoneal    
Orthopedics          
    Acetabular/Pelvic ORIF    
    Amputation    
    Anterior Cruciate Ligament Repair    
    Application of External Fixators    
    Application of Halo Traction    
    Arthroscopy/Arthrotomy    
    Bunionectomy    
    Bursa    
    Carpal Tunnel Release    
    Closed Reduction Fracture    

Page
4
      Circulate       Scrub       Assist
Orthopedics continued 1     2     3     4