Pharmacist Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyPractice Settings/ExperienceAcademia 1 2 3 4 Ambulatory Care 1 2 3 4 Clinic 1 2 3 4 Compounding 1 2 3 4 Consulting 1 2 3 4 Correctional Facility (Jail) 1 2 3 4 Diabetes 1 2 3 4 Drug Information 1 2 3 4 Formulary Management 1 2 3 4 Geriatrics 1 2 3 4 Home Health 1 2 3 4 Home Infusion 1 2 3 4 Hospital– Inpatient 1 2 3 4 Hospital– Outpatient 1 2 3 4 Infectious Disease 1 2 3 4 Long Term Care (LTC) 1 2 3 4 Mail Order 1 2 3 4 Military/Government/VA 1 2 3 4 Nuclear 1 2 3 4 Oncology 1 2 3 4 Pain Management 1 2 3 4 Pediatrics 1 2 3 4 Pharmaceutical Research 1 2 3 4 Pharmaceutical Sales 1 2 3 4 Pharmacy Benefits Management (PBM) 1 2 3 4 Poison Control 1 2 3 4 Psychiatric Patient Management 1 2 3 4 Public Health 1 2 3 4 Renal Patient Management 1 2 3 4 Retail – Chain 1 2 3 4 Retail – Independent 1 2 3 4 Sub-Acute Care 1 2 3 4 Veterinary 1 2 3 4 OtherOtherOtherPharmacy Software SystemsEtreby 1 2 3 4 HBS 1 2 3 4 JASRx 1 2 3 4 McKesson– 3PM 1 2 3 4 McKesson– Pharmserv 1 2 3 4 Meditech 1 2 3 4 NDC 1 2 3 4 OPUS– ISM 1 2 3 4 OSCOR 1 2 3 4 PDX 1 2 3 4 PharmNet 1 2 3 4 Pharmtrak 1 2 3 4 PROScript 2000 1 2 3 4 QS1 1 2 3 4 Renlar 1 2 3 4 Rescot– Omni-DX 1 2 3 4 Rx-Link 1 2 3 4 Speed Script 1 2 3 4 TechRx 1 2 3 4 WinPharm 1 2 3 4 OtherAutomationAccumed/Baker Cells 1 2 3 4 BAXA – Rapid-Fill (ASF) 1 2 3 4 BAXA – Repeater Pump 1 2 3 4 Baxter 1 2 3 4 Baxter – AUTOMIX Compounder 1 2 3 4 Baxter – MICROMIX Compounder 1 2 3 4 Kirby Lester 1 2 3 4 McKesson – AcuDose-Rx 1 2 3 4 McKesson – Baker Scale 1 2 3 4 McKesson – IntelliShelf-Rx 1 2 3 4 McKesson – MedCarousel 1 2 3 4 McKesson – ROBOT– Rx 1 2 3 4 McKesson – PACMED 1 2 3 4 MTS – Automated Sealers 1 2 3 4 MTS – Prepackaging 1 2 3 4 Parata – PACMED 1 2 3 4 Parata – RDS 1 2 3 4 Parata – APM 1 2 3 4 PharmASSIST– RDS ROBOTx 1 2 3 4 PharmASSIST – ROBOTx 1 2 3 4 PharmASSIST – SmartCabinet 1 2 3 4 PharmASSIST – SmartScale 1 2 3 4 Pyxis 1 2 3 4 OtherOtherDisease State ManagementAIDS/HIV 1 2 3 4 Anticoagulation 1 2 3 4 Asthma 1 2 3 4 Cardiovascular Disease 1 2 3 4 Chemotherapy 1 2 3 4 Cystic Fibrosis 1 2 3 4 Depression 1 2 3 4 Diabetes 1 2 3 4 Dyslipidemia 1 2 3 4 Hormone Replacement Therapy 1 2 3 4 Hypertension 1 2 3 4 Osteoporosis 1 2 3 4 Pain Management 1 2 3 4 Smoking Cessation 1 2 3 4 Transplant 1 2 3 4 OtherOtherOtherClinical and Job related ExperienceAdmixture 1 2 3 4 Adolescent Care 1 2 3 4 Aseptic Techniques 1 2 3 4 Blister Packs 1 2 3 4 Cart Check 1 2 3 4 Cart Fill 1 2 3 4 Chemotherapy 1 2 3 4 Computerized Physician Order Entry 1 2 3 4 Consulting 1 2 3 4 Discharge Counseling 1 2 3 4 DME Equipment 1 2 3 4 Drug Information 1 2 3 4 Drug Information Rounds 1 2 3 4 Drug Rehabilitation Programs 1 2 3 4 Emergency Room 1 2 3 4 Enteral Nutrition Products 1 2 3 4 Formulary Management 1 2 3 4 Geriatric Care 1 2 3 4 Hazardous Drug Handling 1 2 3 4 Homeopathic Treatments 1 2 3 4 Hyperalimentation Calculation 1 2 3 4 Immunizations 1 2 3 4 Immunoglobulin Therapy 1 2 3 4 Incontinence Supplies 1 2 3 4 Infectious Disease 1 2 3 4 Infusion Pumps and Systems 1 2 3 4 Intensive Care (ICU) 1 2 3 4 IV Preparation 1 2 3 4 Neonatal Intensive Care (NICU) 1 2 3 4 Oncology 1 2 3 4 Ostomy Supplies 1 2 3 4 OTC selection and recommendations 1 2 3 4 P&T committee participant 1 2 3 4 Pain Management 1 2 3 4 PCA Pumps 1 2 3 4 Pediatric Care 1 2 3 4 Poison Control 1 2 3 4 Psychiatric Care 1 2 3 4 Retail Compounding 1 2 3 4 Surgical Supplies 1 2 3 4 Tocolytic Therapy 1 2 3 4 TPN Preparation 1 2 3 4 Transplant Therapy 1 2 3 4 Urological Supplies 1 2 3 4 OtherOtherAge Specific CompetenciesInfant (birth to 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 Pharmacokinetic Dosing ofAminoglycosides 1 2 3 4 Anticoagulation 1 2 3 4 Digoxin 1 2 3 4 Lithium 1 2 3 4 Theophylline 1 2 3 4 Vancomycin 1 2 3 4 OtherOtherOtherAuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Pharmacist Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.Your NameYour NameYour NameYour Name
