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Cardiac Monitor Technician

    Instruction

    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
Recruiter Information

Recruiter TEEMA email

Personal Information

Full Name

Email

Phone number

Last 4 of Social Security Number

Date

Experience In the Following Setting(s)

Telemetry Unit (located on the unit)

Remote Telemetry Office

# Monitors Responsible For

Patient/Equipment Preparation

Skin prep

Lead Placement - 3 Lead

Lead Placement - 5 Lead

Set up MCL1

Set up Lead II

Set up 12 Lead ECG

Interpret The Following Rhythms

Normal Sinus Rhythm

Sinus Bradycardia/Sinus Tachycardia

Premature Atrial Contractions

Atrial Flutter

Atrial Fibrillation

Junctional Rhythms

PVC - Unifocal/Multifocal

PVC- Bigeminy/Trigeminy/Coupling

Ventricular Tachycardia

Ventricular Fibrillation

1st Degree Heart Block

2nd Degree Heart Block Type I

2nd Degree Heart Block Type II

3rd Degree Heart Block

Sinus Arrest

Asystole

Bundle Branch Block

Paced Rhythms - Atrial/Ventricular/AV

Pacemaker Misfire

Pacemaker- Failure to Capture

Measure Cardiac Rate

Measure Cardiac Intervals (PR, QRS, ST, etc.)

Monitoring System Used

GE

Philips

Spacelabs

Miscellaneous

Cardiac Arrest Protocol

Computerized Charting

Registrations/Certifications

BLS (Exp. Date)

Telemetry Interpretation Course (Date taken)

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I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a Healthcare Professional with those facilities.

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