Sterile Processing Tech 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 independentlyProcessingSingle instruments 1 2 3 4 Endoscopes 1 2 3 4 Repair 1 2 3 4 Sets/Trays 1 2 3 4 Care of instruments 1 2 3 4 Other Processing DecontaminationManual cleaning 1 2 3 4 Washer sterilizer 1 2 3 4 Soiled linen 1 2 3 4 Disinfectants 1 2 3 4 Sharps 1 2 3 4 Disposable items 1 2 3 4 Cleaning equipment 1 2 3 4 Detergents 1 2 3 4 Dress code 1 2 3 4 Other Decontamination Steam SterilizationChart recording 1 2 3 4 Biological monitoring 1 2 3 4 Time 1 2 3 4 Testing/ Monitoring 1 2 3 4 Other Steam Sterilization TestsTest control 1 2 3 4 Recording 1 2 3 4 Other Tests Assembly and PreparationWrapping materials 1 2 3 4 Autoclave tape 1 2 3 4 Dust covers 1 2 3 4 Proper towel/linen folding 1 2 3 4 Proper labeling 1 2 3 4 Expiration dates 1 2 3 4 Packing for steam 1 2 3 4 Heat sealing 1 2 3 4 Instrument count sheets 1 2 3 4 Placing instruments on trays 1 2 3 4 Other Assembly and Preparation Age Specific CompetenciesInfant (Birth - 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 AuthorizationsSignature(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 Sterile Processing Tech Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
