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Nurse Extern Applicant Competency Skills Verification Form
*Skills must be demonstrated in simulated lab or clinical setting*
Name: _____________________________________
Last five of SS # ____________________________
Dear Nursing Instructor – this student is applying to the GHS Nurse Extern Program. Documentation verifying
competency of the fundamental nursing knowledge and skills listed below is a required. Please provide date
validated, your initials and any comments you would like to share.
Thank you in advance for your time.
Fundamental Knowledge/Skill
Date
Validated
Instructor’s
Initials
Comments
Vital Signs (Pulse, Resp. rate, BP, Pain)
Oxygen Therapy Principles:
a. O2 Set-Up/Modes of Delivery
b. Pulse Oximetry
c. Incentive Spirometry
Infection Control Principles:
a. Hand Hygiene
b. Gowning & Gloving for Isolation
Urinary Catheterization
Sterile Technique Principles:
a. Aseptic Technique/Sterile Dressing
Patient Care Principles:
a. Bathing (full assist, partial, self-care)
b. Eating (full, partial, assist)
c. Ambulation
 Transfer to Chair
 Transfer to Bed
 Assist to ambulate
Intake & Output/ Monitor & Record
Comments:
Instructor (Print Name)
(Signature)
Extern Program Applicant: completion and return of this form is a required part of your application packet.
Completed form must be submitted prior to the application deadline of January 13, 2017 to
Rhonda Hovious at [email protected]
(Initials)