Pharmacist Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY 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.
