* = Required Information
Please mark the corresponding experience level for each section
A - Able to perform without any supervision
B - Perform infrequently (Would require some supervision )
C - No experience (Require Assistance / Supervision )
A. GENERAL SURGERY
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
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A B C
B. ORTHOPEDIC
A B C
A B C
A B C
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A B C
A B C
A B C
C. NEURO
A B C
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A B C
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A B C
A B C
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A B C
A B C
A B C
A B C
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A B C
D. GYN
A B C
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A B C
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A B C
A B C
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A B C
A B C
E. UROLOGICAL
A B C
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A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
F. Thoracic/Cardiovascular
A B C
A B C
A B C
A B C
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G. Vascular
A B C
A B C
A B C
A B C
A B C
A B C
A B C
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A B C
H. Ear, Nose & Throat
A B C
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I. EYE
A B C
A B C
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A B C
A B C
A B C
A B C
A B C
A B C
J. ORAL
A B C
A B C
A B C
A B C
K. PLASTIC
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
L. Endoscopic
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
A B C
M. CARDIOVASCULAR RESUSCITATION
A B C
A B C
A B C
A B C
N. Trauma
A B C
A B C
A B C
A B C
O. INTRAVENOUS THERAPY
A B C
A B C
A B C
A B C
A B C
P. MISCELLANEOUS EQUIPMENT
A B C
A B C
A B C
A B C
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A B C
AGE EXPERIENCE
Indicate groups in which you have expertise in providing, age-appropriate nursing care.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
The information that I have given is accurate and true to the best of my knowledge. I hereby authorize Pace Medical Staffing, Inc. to release same to her client health care facilities.

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