GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the Oncology discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

MEDICATIONS / IV THERAPY

1

2

3

4

Administer PO Medications

Administer IM / SQ Medications

Administer IV Medications

Needle-less Systems

Infusion Pumps

Establish Peripheral IVs

Discontinue Peripheral IVs

Pain Assessment / Management

Draw Blood for Lab Studies

Admin Blood / Blood Products

Central Venous Lines (CVL)

Hickman / Broviac Catheters

PCA / CADD

Port-A-Cath

Infusaid

Infuse-A-Port

CARE OF ONCOLOGICAL PATIENT

1

2

3

4

Head, Neck, Chest

Hematologic System

Gastrointestinal Tract

Reproductive System

Skin (Melanomas / Nonmelanomas)

Urinary Tract

EMERGENCIES

1

2

3

4

Cardiac Tamponade

Dissesminated Intravascular Coagulation

Hypercalcemia

Organ Obstruction

Sepsis

Spinal Cord Compression

Superior Vena Cavae Syndrome

Tumor Lysis Syndrome

FAMILY / PSYCHOSOCIAL NEEDS

1

2

3

4

Patient / Family Education

Advance Directives

Acute Phase

Chronic Phase

Terminal Phase

Bereavement Phase

After Treatment (Survivorship)

ANTINEOPLASTIC AGENTS

1

2

3

4

Bleomycin

Dactinomycin (Actinomycin)

Daunorubicin (DaunoXome)

Doxorubicin (Adriamycin)

ROUTS OF ADMINISTRATION

1

2

3

4

Oral / SQ / IM

Oral / SQ / IM

Intraarterial

Intrathecal / Intraventricular

Intraperitoneal (Tenckhoff Catheter)

Intrapleural

Intravesicular

ALKYLATING AGENTS

1

2

3

4

Bulsulfan (Myleran)

Chlorambucil (Leukeran)

Cisplatin (Platinol)

Cyclophosphamide (Cytoxan)

Mechlorethamine (Mustargen)

ANTIMETABOLITES

1

2

3

4

Cytarabine (Ara-C)

Fluorouracil (5-FU)

Mercaptopurine (6-MP)

Methotrexate

Leucovorin Rescue Protocol

ANTINEOPLASTIC ANTIBIOTICS

1

2

3

4

Bleomycin

Dactinomycin (Actinomycin)

Daunorubicin (DaunoXome)

Doxorubicin (Adriamycin)

Plant Alkaloids

Paclitaxel (Taxol)

Vinblastine (Velban)

Vincristine (Oncovin)

HORMONAL ANTINEOPLASTICS

1

2

3

4

Leuprolide (Lupron)

Megestrol (Megace)

Tamoxifen (Nolvadex)

Testolactone (Teslac)

STAFF MINIMIZE RISK OF EXPOSURE

1

2

3

4

During Preparation

During Administration

During Disposal

CLASSIFICATION OF NEOPLASMS

1

2

3

4

Staging - TNM System

Tissue of Origin

Biologic Behavior

Degree of Cell Differentiation

RADIATION THERAPY (RT)

1

2

3

4

Electromagnetic (Xrays, Gamma Rays)

Particulate (Alpha, Beta)

External Beam Therapy

Knowledge of Early Effects of RT

Knowledge of Interim. Effects of RT

BRACHYTHERAPY (SEALED SOURCES)

1

2

3

4

Interstitial Radiation Therapy

Intracavitary Radiation Therapy

RADIOPHARMACEUTICAL (UNSEALED SOURCES)

1

2

3

4

Tracer Dose

Therapeutic Dose

SURGICAL INTERVENTION

1

2

3

4

Curative Surgery

Diagnostic Surgery

Mechanical Device Insertion

Palliative Surgery

Prophylactic Surgery

Reconstructive Surgery

Rehabilitative Surgery

Bone Marrow Transplant - Allogenic

Bone Marrow Transplant - Syngenic

ONCOLOGY HEALTH CARE SETTINGS

1

2

3

4

Adult

Pediatrics

Cancer Center

Radiation Oncology

Surgical Oncology

Bone Marrow Unit

Research / Clinical Trials

Subacute / Skilled Nursing

Home Health Care

Hospice

Clinic - Risk Assess / Screening / Diagnosis

Clinic - Surgery / Gyn

Clinic - Medical / Hematology

Clinic - Immunology / Infectious

RECOGNITION & MANAGEMENT OF

1

2

3

4

Anxiety / Depression

Metabolic Alterations

Hypersensitivity

Fatigue

HEMATOPOIETIC

1

2

3

4

Anemia

Leukopenia

Thrombocytopenia

GASTROINTESTINAL

1

2

3

4

Anorexia / Dehydration

Nausea / Vomiting

Constipation / Diarrhea

Muscositis / Ulceration

Hepatic Toxicity

Integumentary

Alopecia

Dermatitis

Hyperpigmentation

Genitourinary

Cystitis

Renal Toxicity

CARDIOVASCULAR

1

2

3

4

Cardiac Toxicity

Phlebitis

Extravasation

NEUROLOGIC

1

2

3

4

Neurotoxicity

Ototoxicity

Metabolic Encephalopathy

Peripheral Neuropathy

PULMONARY

1

2

3

4

Fibrosis

Pneumonitis

Edema

REPRODUCTIVE

1

2

3

4

Infertility

Changes in Libido

Erectile Dysfunction

NUTRITION

1

2

3

4

Assess Nutritional Status

Assess / Manage Nutritional Impairment

Interpretation of Lab Values

Oral Feedings

Enteral Tube Feeding

Peripheral Parenteral Nutrition (PPN)

Central TPN

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * 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 Hudson Staffing to release this Oncology Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (3.228.10.17) which will be used as a digital signature.