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RN-Occupational and Employee Health

Information

Name *

Last 4 digits of SSN *

Phone *

Email *

Proficiency Scale

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Trauma

Care of Patient with Minor Trauma *

Care of Patient with Major Trauma *

MAST Suit *

Burns

Care of Patient with First Degree Burns *

Care of Patient with Second Degree Burns *

Care of Patient with Third Degree Burns *

Care of Patient with Electrocution *

Care of Patient with Hazardous Materials Exposure *

Lacerations

Assessment of Lacerations *

Cleansing of Lacerations *

Use of Steri-Strips for Lacerations *

Dressing of Lacerations *

Sprain/Strain

Assessment of Sprain/Strain *

Care of Patient with Carpal Tunnel *

Care of Patient with Tendonitis *

Care of Patient with Epicondylitis *

Physicals

Safety *

Return to Work *

Respirator *

Vital Signs *

Height/Weight *

Blood Draw *

Medical Referral Form *

Medical Certification Form *

Medical History Questionnaire *

Potassium Iodine Assessment *

Restrictions

Temporary Restrictions *

Permanent Restrictions *

Pulmonary Function *

Audiometry *

Vision Testing *

X-ray *

Urine Testing *

Drug Testing *

Breathalyzer *

Immunizations

Havrix (Hepatitis A) *

Influenza Vaccine *

Meningitis Vaccine *

Tetanus & Diphtheria *

Oral Typhoid Vaccine *

Polio Vaccine *

Hepatitis B Vaccine *

Japanese Encephalitis B *

Rabies Vaccine *

Typhim (Injectable Type) *

Yellow Fever Vaccine *

Age Specific Competencies

Newborn (birth to 30 days) *

Infant (30 days - 1 year) *

Toddler (ages 1-3 years) *

Preschooler (3-5 years) *

School Age Children (5-12 years) *

Adolescents (12-18 years) *

Young Adults (18-39 years) *

Middle Adults (39-64 years) *

Older Adults (64+) *

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