[checklist name= "Surgical Technician" mailto="credentialing@teemagroup.com" templatedoc="1YncJ-CguDuVbTkMD-VJBWZSZYllNOEz97kP45LjUa0c" templatedrive="1LG9WAg21_L3L-ZkZEChBzrYRhBOjpmcc" savedrive="15FFQjDXxe9nC9FkAAcuxbswGy1hq4sWm" sheetid="1xJkggLvktsyYL6zuIhdO-OURJhJTkWdDKunR11agspw"] [checklistHeading title="Surgical Technician"] Please rate your experience / frequency (within the last year) using the scale (check the appropriate boxes below) 0 = No theory and/or experience 1 = Limited experience/need supervision and/or support 2 = Experienced/minimal support needed to perform) 3 = Proficient/can perform independently 4 = Expert/very experienced in the field [/checklistHeading] [checklistInputGroup name="Recruiter Information"] [checklistInput type="text"]Recruiter TEEMA email[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Personal Information"] [checklistInput type="text"]Full Name[/checklistInput] [checklistInput type="email"]Your Email[/checklistInput] [checklistInput type="text"]Your phone number[/checklistInput] [checklistInput type="text"]Last 4 of Social Security Number[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="General Skills"] [checklistInput type="scale"]AKA/BKA (amputation)[/checklistInput] [checklistInput type="scale"]Abdominal-Perineal Resection[/checklistInput] [checklistInput type="scale"]Cholecystectomy (Open)[/checklistInput] [checklistInput type="scale"]Exploratory Laparotomy[/checklistInput] [checklistInput type="scale"]Appendectomy[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Laparoscopic Procedure"] [checklistInput type="scale"]Cholecystectomy[/checklistInput] [checklistInput type="scale"]Appendectomy[/checklistInput] [checklistInput type="scale"]Hernia[/checklistInput] [checklistInput type="scale"]Nissan[/checklistInput] [checklistInput type="scale"]Colectomy[/checklistInput] [checklistInput type="scale"]Gastrectomy[/checklistInput] [checklistInput type="scale"]Inguinal / Ventral Hernia Repair[/checklistInput] [checklistInput type="scale"]Splenectomy[/checklistInput] [checklistInput type="scale"]Bowel Resection / Colostomy[/checklistInput] [checklistInput type="scale"]Thyroidectomy[/checklistInput] [checklistInput type="scale"]Rectal Procedures[/checklistInput] [checklistInput type="scale"]Esophagoscopy / Gastroscopy[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Pediatric Case"] [checklistInput type="scale"]Inguinal Hernia Repair[/checklistInput] [checklistInput type="scale"]Pyloric Stenosis[/checklistInput] [checklistInput type="scale"]Circumcision[/checklistInput] [checklistInput type="scale"]Exploratory Laparotomy[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="E.N.T"] [checklistInput type="scale"]Middle Ear Cases[/checklistInput] [checklistInput type="scale"]T&A[/checklistInput] [checklistInput type="scale"]Myringotomy[/checklistInput] [checklistInput type="scale"]Tympanoplasty[/checklistInput] [checklistInput type="scale"]Radical Neck Dissection[/checklistInput] [checklistInput type="scale"]Septoplasty[/checklistInput] [checklistInput type="scale"]Sinus Endoscopy[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Cardiac / Thoracic / Vascular"] [checklistInput type="scale"]Coronary Artery By-pass[/checklistInput] [checklistInput type="scale"]Mitral Valve Repair / Replacement[/checklistInput] [checklistInput type="scale"]Aortic Valve Replacement[/checklistInput] [checklistInput type="scale"]Multiple Valve Transposition[/checklistInput] [checklistInput type="scale"]Septal Defects[/checklistInput] [checklistInput type="scale"]Ventricular Aneurysm Repair[/checklistInput] [checklistInput type="scale"]Bring Back Heart[/checklistInput] [checklistInput type="scale"]Pericardial Window[/checklistInput] [checklistInput type="scale"]Intra-Aortic Balloon Insertion[/checklistInput] [checklistInput type="scale"]Heartport or Similar CABG[/checklistInput] [checklistInput type="scale"]Thoraco Approach Mid-Cab[/checklistInput] [checklistInput type="scale"]Aortic Arch Replacement[/checklistInput] [checklistInput type="scale"]Aortic Valve Conduit[/checklistInput] [checklistInput type="scale"]Mechanical Heart / LVAD[/checklistInput] [checklistInput type="scale"]Pediatric Hearts[/checklistInput] [checklistInput type="scale"]Tetralogy of Fallot[/checklistInput] [checklistInput type="scale"]Chamberlain Procedure[/checklistInput] [checklistInput type="scale"]AICD Insertion[/checklistInput] [checklistInput type="scale"]Saphenous Vein Harvest[/checklistInput] [checklistInput type="scale"]Endoscopic Vein Harvest[/checklistInput] [checklistInput type="scale"]Gastric Artery Harvest[/checklistInput] [checklistInput type="scale"]Radial Vein Harvest[/checklistInput] [checklistInput type="scale"]Insertion Vena Cava Filter[/checklistInput] [checklistInput type="scale"]Thoracotomy[/checklistInput] [checklistInput type="scale"]Thoracoscopy[/checklistInput] [checklistInput type="scale"]Insertion Chest Tube[/checklistInput] [checklistInput type="scale"]Esophageal Repair[/checklistInput] [checklistInput type="scale"]Pneumonectomy / Lobectomy[/checklistInput] [checklistInput type="scale"]Mediastinoscopy[/checklistInput] [checklistInput type="scale"]Descending Aortic Repair[/checklistInput] [checklistInput type="scale"]Arterial Stenting[/checklistInput] [checklistInput type="scale"]Intra-Operative Angioplasty[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Vascular Surgery"] [checklistInput type="scale"]Carotid Endarterectomy[/checklistInput] [checklistInput type="scale"]Abdominal Aortic Aneurysm[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Femoral"] [checklistInput type="scale"]Popliteal By-pass Graft (Insitu)[/checklistInput] [checklistInput type="scale"]Popliteal By-pass Graft (Graph)[/checklistInput] [checklistInput type="scale"]Portacath, Tesio, Hickman Placement[/checklistInput] [checklistInput type="scale"]AV Shunt[/checklistInput] [checklistInput type="scale"]Thrombectomy[/checklistInput] [checklistInput type="scale"]Pacemaker Insertion[/checklistInput] [checklistInput type="scale"]Arterial Stenting[/checklistInput] [checklistInput type="scale"]Intra-Operative Angioplasty[/checklistInput] [checklistInput type="scale"]Subclavian / Carotid By-pass[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Orthopedics"] [checklistInput type="scale"]Total Hip Replacement[/checklistInput] [checklistInput type="scale"]Bipolar Hip[/checklistInput] [checklistInput type="scale"]Compression Hip Screw[/checklistInput] [checklistInput type="scale"]Total Knee Replacement[/checklistInput] [checklistInput type="scale"]Knee Arthroscopy[/checklistInput] [checklistInput type="scale"]ACL Knee Repair[/checklistInput] [checklistInput type="scale"]Harrington Rod or Similar[/checklistInput] [checklistInput type="scale"]I.M. Rodding[/checklistInput] [checklistInput type="scale"]Hand Procedures[/checklistInput] [checklistInput type="scale"]Foot Procedures[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Mini, Standard, Large Fragment"] [checklistInput type="scale"]Screws & Plates[/checklistInput] [checklistInput type="scale"]External Fixation[/checklistInput] [checklistInput type="scale"]Shoulder Repair[/checklistInput] [checklistInput type="scale"]Shoulder Arthroscopy[/checklistInput] [checklistInput type="scale"]Spinal Fusion[/checklistInput] [checklistInput type="scale"]Cast Application[/checklistInput] [checklistInput type="scale"]Fracture Table Set-up[/checklistInput] [checklistInput type="scale"]Drills, Saws and Reamers[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Urology"] [checklistInput type="scale"]Radical Prostatectomy[/checklistInput] [checklistInput type="scale"]Radical Lymph Node Dissection[/checklistInput] [checklistInput type="scale"]Ureteroscopy[/checklistInput] [checklistInput type="scale"]TURP / TURST[/checklistInput] [checklistInput type="scale"]Ultrasonic Lithotripsy[/checklistInput] [checklistInput type="scale"]Hydrocelectomy[/checklistInput] [checklistInput type="scale"]Cystoscopy[/checklistInput] [checklistInput type="scale"]Insertion Penile Prosthesis[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Gynecology"] [checklistInput type="scale"]D & C[/checklistInput] [checklistInput type="scale"]Diagnostic Laparoscopy[/checklistInput] [checklistInput type="scale"]Laparoscopic Vaginal Hysterectomy[/checklistInput] [checklistInput type="scale"]Abdominal Hysterectomy[/checklistInput] [checklistInput type="scale"]Vaginal Hysterectomy[/checklistInput] [checklistInput type="scale"]Anterior Repair[/checklistInput] [checklistInput type="scale"]Posterior Repair[/checklistInput] [checklistInput type="scale"]MMK (Marshall Marchetti Krantz)[/checklistInput] [checklistInput type="scale"]Tuboplasty[/checklistInput] [checklistInput type="scale"]BTL (Bilateral Tubal Ligation)[/checklistInput] [checklistInput type="scale"]C-Sections[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Neurology"] [checklistInput type="scale"]Cervical Laminectomy (Anterior)[/checklistInput] [checklistInput type="scale"]Cervical Laminectomy (Posterior)[/checklistInput] [checklistInput type="scale"]Lumbar Laminectomy Discectomy[/checklistInput] [checklistInput type="scale"]Percutaneous Micro Discectomy[/checklistInput] [checklistInput type="scale"]Craniotomy For Tumor[/checklistInput] [checklistInput type="scale"]Craniotomy For Aneurysm[/checklistInput] [checklistInput type="scale"]Burr Holes[/checklistInput] [checklistInput type="scale"]VP Shunts[/checklistInput] [checklistInput type="scale"]Transsphenoidal Hypothypectomy[/checklistInput] [checklistInput type="scale"]Carpal Tunnel Repair[/checklistInput] [checklistInput type="scale"]Harrington Rod or Similar[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Trauma Surgery"] [checklistInput type="scale"]Transplant Surgery[/checklistInput] [checklistInput type="scale"]Organ Procurement (Harvest)[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Plastics"] [checklistInput type="scale"]Mammoplasty[/checklistInput] [checklistInput type="scale"]Facelifts[/checklistInput] [checklistInput type="scale"]Skin Grafts[/checklistInput] [checklistInput type="scale"]Rhinoplasty[/checklistInput] [checklistInput type="scale"]Cleft Lip Repair[/checklistInput] [checklistInput type="scale"]Abdominalplasty[/checklistInput] [checklistInput type="scale"]Blepharoplasty[/checklistInput] [checklistInput type="scale"]Otoplasty[/checklistInput] [checklistInput type="scale"]Muscle Flaps[/checklistInput] [/checklistInputGroup] [checklistInputGroup name="Age Specific"] [checklistInput type="scale"]Infant (Birth - 1 year)[/checklistInput] [checklistInput type="scale"]Preschooler (ages 2-5 years)[/checklistInput] [checklistInput type="scale"]Childhood (ages 6-12 years)[/checklistInput] [checklistInput type="scale"]Adolescents (ages 13-21 years)[/checklistInput] [checklistInput type="scale"]Young Adults (ages 22-39 years)[/checklistInput] [checklistInput type="scale"]Adults (ages 40-64 years)[/checklistInput] [checklistInput type="scale"]Older Adults (ages 65-79 years)[/checklistInput] [checklistInput type="scale"]Elderly (ages 80+ years)[/checklistInput] [/checklistInputGroup] [checklistFooter] [/checklistFooter] [/checklist]