Surgical 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 independentlySkill LevelAKA/BKA (amputation) 1 2 3 4 Abdominal-Perineal Resection 1 2 3 4 Cholecystectomy (Open) 1 2 3 4 Exploratory Laparotomy 1 2 3 4 Appendectomy 1 2 3 4 Laparoscopic ProcedureCholecystectomy 1 2 3 4 Appendectomy 1 2 3 4 Hernia 1 2 3 4 Nissan 1 2 3 4 Colectomy 1 2 3 4 Gastrectomy 1 2 3 4 Inguinal / Ventral Hernia Repair 1 2 3 4 Spienectomy 1 2 3 4 Bowel Resection / Colostomy 1 2 3 4 Thyroidectomy 1 2 3 4 Rectal Procedures 1 2 3 4 Esophagascopy / Gastroscopy 1 2 3 4 Pediatric CaseInguinal Hernia Repair 1 2 3 4 Pyloric Stenosis 1 2 3 4 Circumcision 1 2 3 4 Exploratory Laparotomy 1 2 3 4 E.N.TMiddle Ear Cases 1 2 3 4 T&A 1 2 3 4 Myringotomy 1 2 3 4 Tympanoplasty 1 2 3 4 Radical Neck Dissection 1 2 3 4 Septoplasty 1 2 3 4 Sinus Endoscopy 1 2 3 4 Cardiac / Thoracic / VascularCoronary Artery By-pass 1 2 3 4 Mitral Valve Repair / Replacement 1 2 3 4 Aortic Valve Replacement 1 2 3 4 Multiple Valve Transposition 1 2 3 4 Septal Defects 1 2 3 4 Ventricular Aneurysm Repair 1 2 3 4 Bring Back Heart 1 2 3 4 Pericardial Window 1 2 3 4 Intra-Aortic Balloon Insertion 1 2 3 4 Heartport or Similar CABG 1 2 3 4 Thoraco Approach Mid-Cab 1 2 3 4 Aortic Arch Replacement 1 2 3 4 Aortic Valve Conduit 1 2 3 4 Mechanical Heart / LVAD 1 2 3 4 Pediatric Hearts 1 2 3 4 Tetrology of Fallot 1 2 3 4 Chamberlin Procedure 1 2 3 4 AICD Insertion 1 2 3 4 Saphenous Vein Harvest 1 2 3 4 Endoscopic Vein Harvest 1 2 3 4 Gastric Artery Harvest 1 2 3 4 Radial Vein Harvest 1 2 3 4 Insertion Vena Cava Filter 1 2 3 4 Thoracotomy 1 2 3 4 Thoracoscopy 1 2 3 4 Insertion Chest Tube 1 2 3 4 Esophageal Repair 1 2 3 4 Pneurnonectomy / Lobectomy 1 2 3 4 Mediastinodcopy 1 2 3 4 Desendind Aortic Repair 1 2 3 4 Arterial Stenting 1 2 3 4 Intra-Operative Angioplasty 1 2 3 4 Vascular SurgeryCarotid Endarterectomy 1 2 3 4 Abdominal Aortic Aneurysm 1 2 3 4 FemoralPopliteal By-pass Graft (Insitu) 1 2 3 4 Popliteal By-pass Graft (Graph) 1 2 3 4 Portacath, Tesio, Hickman Placement 1 2 3 4 AV Shunt 1 2 3 4 Thrombectomy 1 2 3 4 Pacemaker Insertion 1 2 3 4 Arterial Stenting 1 2 3 4 Intra-Operative Angioplasty 1 2 3 4 Subclavin / Carotid By-pass 1 2 3 4 OrthopedicsTotal Hip Replacement 1 2 3 4 Bipolar Hip 1 2 3 4 Compression Hip Screw 1 2 3 4 Total Knee Replacement 1 2 3 4 Knee Arthroscopy 1 2 3 4 ACL Knee Repair 1 2 3 4 Harrington Rod or Similar 1 2 3 4 I.M. Rodding 1 2 3 4 Hand Procedures 1 2 3 4 Foot Procedures 1 2 3 4 Mini, Standard, Large FragmentScrews & Plates 1 2 3 4 External Fixation 1 2 3 4 Shoulder Repair 1 2 3 4 Shoulder Arthroscopy 1 2 3 4 Spinal Fusion 1 2 3 4 Cast Application 1 2 3 4 Fracture Table Set-up 1 2 3 4 Drills, Saws and Reamers 1 2 3 4 UrologyRadical Prostatectomy 1 2 3 4 Radical Lymph Node Dissection 1 2 3 4 Ureteroscopy 1 2 3 4 TURP / TURST 1 2 3 4 Ultrasonic Lithotripsy 1 2 3 4 Hydrocelectomy 1 2 3 4 Cystoscopy 1 2 3 4 Insertion Penile Prosthesis 1 2 3 4 GynecologyD & C 1 2 3 4 Diagnostic Laparascope 1 2 3 4 Laparoscopic Vaginal Hysterectomy 1 2 3 4 Abdominal Hysterectomy 1 2 3 4 Vaginal Hysterectomy 1 2 3 4 Anterior Repair 1 2 3 4 Posterior Repair 1 2 3 4 MMK (Marshall Marchetti Krantz) 1 2 3 4 Tuboplasty 1 2 3 4 BTL (Bilateral Tubal Ligation) 1 2 3 4 C-Sections 1 2 3 4 NeurologyCervical Laminectomy (Anterior) 1 2 3 4 Cervical Laminectomy (Posterior) 1 2 3 4 Lumbar Laminectomy Discectomy 1 2 3 4 Percutaneous Micro Discectomy 1 2 3 4 Craniotomy For Tumor 1 2 3 4 Craniotomy For Aneurysm 1 2 3 4 Burr Holes 1 2 3 4 VP Shunts 1 2 3 4 Transphenoidal Hypothypectomy 1 2 3 4 Carpal Tunnel Repair 1 2 3 4 Harrington Rod or Similar 1 2 3 4 Trauma SurgeryTransplant Surgery 1 2 3 4 Organ Procurement (Harvest) 1 2 3 4 PlasticsMammoplasty 1 2 3 4 Facelifts 1 2 3 4 Skin Grafts 1 2 3 4 Rhinoplasty 1 2 3 4 Cleft Lip Repair 1 2 3 4 Abdominalplasty 1 2 3 4 Blepharoplasty 1 2 3 4 Otoplasty 1 2 3 4 Muscle Flaps 1 2 3 4 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 Surgical Tech Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
