Please enable Javascript in your browser to use this form

Pediatric Clinical Capabilities Checklist

 
Note: First Name, Last Name, Email Address, as well as Signature Name and Date Completed (at the bottom of the checklist) are required. All other fields are optional.
First Name Middle Name Last Name
Email Address
 
  Certifications  
 
BLS BLS Exp. Date NALS NALS Exp. Date
Yes No / / Yes No / /
 
ATLS ATLS Exp. Date ABLS ABLS Exp. Date
No / / Yes No / /
 
PALS PALS Exp. Date NRP NRP Exp. Date
Yes No / / Yes No / /
 
Please check the box indicating which clinical capabilities you are able to preform, and, where indicated ("#"), list the approximate number performed with the last 24 months.
 
Clinical Areas
*Definition: Inpatient and Outpatient settings may include evaluation and treatment of orthopedic, surgical procedures, minor gynecologic, and uncomplicated psychiatric issues; stabilization for transport of patients with potentially life-threatening emergencies of a medical, surgical, traumatic, or thermal nature
 
Nursery Services
 
 
  Diagnosis and management of newborns with serious or critical illnesses; ventilator assistance may or may not be needed; ability to transfer to higher level of care if indicated
 
Procedures
Insertion of:
#
#
#
 
#
#
#
#
 
Please list any procedures customary to your specialty training that you are not comfortable performing (maximum 254 characters)

You have 254 characters remaining
 
  Disclaimer  
 
The information I have given is true and accurate to the best of my knowledge. By clicking the submit button I hereby authorize Advantage Locums, LLC to release this Pediatrics Clinical Capabilities Checklist to facilities of Advantage Locums, LLC in relation to consideration of my employment.
 
Signature Name Date Completed
/ /
 
Save your work so you can update or complete it later Submit your information via email
 


Member of the National Association of Locum Tenens Organizations (NALTO)Member of the National Association of Physician Recruiters (NAPR)

Advantage Locums is a proud member of the
National Association of Locum Tenens Organizations
and National Association of Physician Recruiters.