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Primary Care 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 ACLS ACLS 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.
 
Settings

Medicine
 
 
 
 

Pediatric
 
 
 
 

GYN
 
 
 
 
 

Orthopedic
 
 

Surgery
 
 
 
 

Psychiatric
 
 
 
 
Occupational Medicine
OB
 
Date of last delivery: / /
 
* Physicians who recently completed residency must provide the number for the last 36 months
Within Last: 12 months 12-24 months 24-36 months*
Vaginal Deliveries
C-sections
VBAC
Instrument assisted deliveries (forceps, vacuum, etc.)
Ultrasounds

Procedures
Please include the number for the last two years
#
Insertion of:
#
#
#
#
Diagnostic/therapeutic taps:
#
#
 
** Ventilation management - establishing and maintaining an airway; various modes of ventilation for up to 24 hours without pulmonary consultation
 
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 Primary Care Clinical Capabilities Checklist to facilities of Advantage Locums, LLC in relation to consideration of my employment.
 
Signature Name Date Completed
/ /
 
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