Correctional Skills Assessment

Congrats on taking the necessary step to applying for a travel nursing position with us! Before we can offer you an amazing nursing assignment, the following skills assessment must be completed. Take your time and review your information before submitting. We look forward to seeing your results!

Instructions:

This checklist is for assessing your experience in specific clinical areas. It will not be a determining factor in accepting your application to become an employee of Trusted Nurse Staffing LLC.

Please rate your experience using the following scale (check the appropriate boxes below):

0 = No Experience / Observed Only
1 = Less than 1 year experience
2 = 1 - 2 years of experience
3 = Over 2 years of experience

Your Information:

Today's Date: This question requires a valid date format of MM/DD/YYYY.

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First Name

Last Name

Email Address

Phone Number

GENERAL NURSING, Part 1

Space Cell	0	1	2	3
Correctional Health Admissions	Correctional Health Admissions: 0	Correctional Health Admissions: 1	Correctional Health Admissions: 2	Correctional Health Admissions: 3
Data Collection for Vital Signs/Height/Weight	Data Collection for Vital Signs/Height/Weight: 0	Data Collection for Vital Signs/Height/Weight: 1	Data Collection for Vital Signs/Height/Weight: 2	Data Collection for Vital Signs/Height/Weight: 3
Assist with Routine Health Services	Assist with Routine Health Services: 0	Assist with Routine Health Services: 1	Assist with Routine Health Services: 2	Assist with Routine Health Services: 3
Assist with First Aide	Assist with First Aide: 0	Assist with First Aide: 1	Assist with First Aide: 2	Assist with First Aide: 3
Initiates Emergency Procedures	Initiates Emergency Procedures: 0	Initiates Emergency Procedures: 1	Initiates Emergency Procedures: 2	Initiates Emergency Procedures: 3
Discharge Physicals/Inmates	Discharge Physicals/Inmates: 0	Discharge Physicals/Inmates: 1	Discharge Physicals/Inmates: 2	Discharge Physicals/Inmates: 3
Supervise Unlicensed Personnel	Supervise Unlicensed Personnel: 0	Supervise Unlicensed Personnel: 1	Supervise Unlicensed Personnel: 2	Supervise Unlicensed Personnel: 3
Pulse Oximetry	Pulse Oximetry: 0	Pulse Oximetry: 1	Pulse Oximetry: 2	Pulse Oximetry: 3
Urine Dipstick	Urine Dipstick: 0	Urine Dipstick: 1	Urine Dipstick: 2	Urine Dipstick: 3
Blood Glucose Monitoring	Blood Glucose Monitoring: 0	Blood Glucose Monitoring: 1	Blood Glucose Monitoring: 2	Blood Glucose Monitoring: 3
Assist w/ Basic Treatment Procedures	Assist w/ Basic Treatment Procedures: 0	Assist w/ Basic Treatment Procedures: 1	Assist w/ Basic Treatment Procedures: 2	Assist w/ Basic Treatment Procedures: 3
Wound Care / Debridement	Wound Care / Debridement: 0	Wound Care / Debridement: 1	Wound Care / Debridement: 2	Wound Care / Debridement: 3
Dressing Changes	Dressing Changes: 0	Dressing Changes: 1	Dressing Changes: 2	Dressing Changes: 3
Wound Drains (JP/Hemovac)	Wound Drains (JP/Hemovac): 0	Wound Drains (JP/Hemovac): 1	Wound Drains (JP/Hemovac): 2	Wound Drains (JP/Hemovac): 3
Positioning / Transferring	Positioning / Transferring: 0	Positioning / Transferring: 1	Positioning / Transferring: 2	Positioning / Transferring: 3
Pre-Operative Care/Preparation	Pre-Operative Care/Preparation: 0	Pre-Operative Care/Preparation: 1	Pre-Operative Care/Preparation: 2	Pre-Operative Care/Preparation: 3
Universal Precautions	Universal Precautions: 0	Universal Precautions: 1	Universal Precautions: 2	Universal Precautions: 3
Center for Disease Control Guidelines	Center for Disease Control Guidelines: 0	Center for Disease Control Guidelines: 1	Center for Disease Control Guidelines: 2	Center for Disease Control Guidelines: 3

GENERAL NURSING, Part 2

Space Cell	0	1	2	3
Isolation Techniques	Isolation Techniques: 0	Isolation Techniques: 1	Isolation Techniques: 2	Isolation Techniques: 3
Wrist Restraints	Wrist Restraints: 0	Wrist Restraints: 1	Wrist Restraints: 2	Wrist Restraints: 3
Full Restraints	Full Restraints: 0	Full Restraints: 1	Full Restraints: 2	Full Restraints: 3
Ambulatory Cuffs	Ambulatory Cuffs: 0	Ambulatory Cuffs: 1	Ambulatory Cuffs: 2	Ambulatory Cuffs: 3
Alarm Systems	Alarm Systems: 0	Alarm Systems: 1	Alarm Systems: 2	Alarm Systems: 3
Cultural Diversity	Cultural Diversity: 0	Cultural Diversity: 1	Cultural Diversity: 2	Cultural Diversity: 3
Ethnic Awareness	Ethnic Awareness: 0	Ethnic Awareness: 1	Ethnic Awareness: 2	Ethnic Awareness: 3

MEDS/IV THERAPY

Space Cell	0	1	2	3
Administer PO Medications	Administer PO Medications: 0	Administer PO Medications: 1	Administer PO Medications: 2	Administer PO Medications: 3
Administer IM & SQ Meds	Administer IM & SQ Meds: 0	Administer IM & SQ Meds: 1	Administer IM & SQ Meds: 2	Administer IM & SQ Meds: 3
Peripheral IV Insertion	Peripheral IV Insertion: 0	Peripheral IV Insertion: 1	Peripheral IV Insertion: 2	Peripheral IV Insertion: 3
Use of Heparin/Saline Locks	Use of Heparin/Saline Locks: 0	Use of Heparin/Saline Locks: 1	Use of Heparin/Saline Locks: 2	Use of Heparin/Saline Locks: 3
Needle-less Systems	Needle-less Systems: 0	Needle-less Systems: 1	Needle-less Systems: 2	Needle-less Systems: 3
Administer IV Medications	Administer IV Medications: 0	Administer IV Medications: 1	Administer IV Medications: 2	Administer IV Medications: 3
Discontinue Peripheral IVs	Discontinue Peripheral IVs: 0	Discontinue Peripheral IVs: 1	Discontinue Peripheral IVs: 2	Discontinue Peripheral IVs: 3
Pain Assessment/Management	Pain Assessment/Management: 0	Pain Assessment/Management: 1	Pain Assessment/Management: 2	Pain Assessment/Management: 3
Venipuncture for Lab Work	Venipuncture for Lab Work: 0	Venipuncture for Lab Work: 1	Venipuncture for Lab Work: 2	Venipuncture for Lab Work: 3
Prepare Specimens for Lab	Prepare Specimens for Lab: 0	Prepare Specimens for Lab: 1	Prepare Specimens for Lab: 2	Prepare Specimens for Lab: 3

RESPIRATORY

Space Cell	0	1	2	3
Establish Airway	Establish Airway: 0	Establish Airway: 1	Establish Airway: 2	Establish Airway: 3
Assist with Intubation (ETT)	Assist with Intubation (ETT): 0	Assist with Intubation (ETT): 1	Assist with Intubation (ETT): 2	Assist with Intubation (ETT): 3
Ventilate with Ambu-bag	Ventilate with Ambu-bag: 0	Ventilate with Ambu-bag: 1	Ventilate with Ambu-bag: 2	Ventilate with Ambu-bag: 3
Suctioning	Suctioning: 0	Suctioning: 1	Suctioning: 2	Suctioning: 3
Incentive Spirometry	Incentive Spirometry: 0	Incentive Spirometry: 1	Incentive Spirometry: 2	Incentive Spirometry: 3
Nasal Cannula	Nasal Cannula: 0	Nasal Cannula: 1	Nasal Cannula: 2	Nasal Cannula: 3
Face Masks	Face Masks: 0	Face Masks: 1	Face Masks: 2	Face Masks: 3
Assessment of Breath Sounds	Assessment of Breath Sounds: 0	Assessment of Breath Sounds: 1	Assessment of Breath Sounds: 2	Assessment of Breath Sounds: 3
Ambuing techniques	Ambuing techniques: 0	Ambuing techniques: 1	Ambuing techniques: 2	Ambuing techniques: 3

NEUROLOGY

Space Cell	0	1	2	3
Neuro Assessment / Vital Signs	Neuro Assessment / Vital Signs: 0	Neuro Assessment / Vital Signs: 1	Neuro Assessment / Vital Signs: 2	Neuro Assessment / Vital Signs: 3
Seizure Precautions	Seizure Precautions: 0	Seizure Precautions: 1	Seizure Precautions: 2	Seizure Precautions: 3
Assist with Lumbar Puncture	Assist with Lumbar Puncture: 0	Assist with Lumbar Puncture: 1	Assist with Lumbar Puncture: 2	Assist with Lumbar Puncture: 3

ADMINISTRATIVE DUTIES

Space Cell	0	1	2	3
Documentation	Documentation: 0	Documentation: 1	Documentation: 2	Documentation: 3
Maintain Clinic Flow	Maintain Clinic Flow: 0	Maintain Clinic Flow: 1	Maintain Clinic Flow: 2	Maintain Clinic Flow: 3
Order Supplies/Equipment	Order Supplies/Equipment: 0	Order Supplies/Equipment: 1	Order Supplies/Equipment: 2	Order Supplies/Equipment: 3
Restock Infirmary	Restock Infirmary: 0	Restock Infirmary: 1	Restock Infirmary: 2	Restock Infirmary: 3
Use Computer to Obtain/Enter Info	Use Computer to Obtain/Enter Info: 0	Use Computer to Obtain/Enter Info: 1	Use Computer to Obtain/Enter Info: 2	Use Computer to Obtain/Enter Info: 3
Assemble Medical Record	Assemble Medical Record: 0	Assemble Medical Record: 1	Assemble Medical Record: 2	Assemble Medical Record: 3
Maintain Medical Record	Maintain Medical Record: 0	Maintain Medical Record: 1	Maintain Medical Record: 2	Maintain Medical Record: 3
Manage Provider Orders	Manage Provider Orders: 0	Manage Provider Orders: 1	Manage Provider Orders: 2	Manage Provider Orders: 3
Schedule Appointments	Schedule Appointments: 0	Schedule Appointments: 1	Schedule Appointments: 2	Schedule Appointments: 3
Maintains Unit Logs/Records	Maintains Unit Logs/Records: 0	Maintains Unit Logs/Records: 1	Maintains Unit Logs/Records: 2	Maintains Unit Logs/Records: 3
Multi-Disciplinary Planning	Multi-Disciplinary Planning: 0	Multi-Disciplinary Planning: 1	Multi-Disciplinary Planning: 2	Multi-Disciplinary Planning: 3
OSHA Guidelines	OSHA Guidelines: 0	OSHA Guidelines: 1	OSHA Guidelines: 2	OSHA Guidelines: 3
Inmate/patient Education	Inmate/patient Education: 0	Inmate/patient Education: 1	Inmate/patient Education: 2	Inmate/patient Education: 3

CARDIAC

Space Cell	0	1	2	3
Cardiac Assessment Vital Signs	Cardiac Assessment Vital Signs: 0	Cardiac Assessment Vital Signs: 1	Cardiac Assessment Vital Signs: 2	Cardiac Assessment Vital Signs: 3
Perform 12-lead EKG	Perform 12-lead EKG: 0	Perform 12-lead EKG: 1	Perform 12-lead EKG: 2	Perform 12-lead EKG: 3
Assist with Code	Assist with Code: 0	Assist with Code: 1	Assist with Code: 2	Assist with Code: 3
Defibrillation/Cardioversion	Defibrillation/Cardioversion: 0	Defibrillation/Cardioversion: 1	Defibrillation/Cardioversion: 2	Defibrillation/Cardioversion: 3
Cardiac Arrest / CPR	Cardiac Arrest / CPR: 0	Cardiac Arrest / CPR: 1	Cardiac Arrest / CPR: 2	Cardiac Arrest / CPR: 3

GENITOURINARY

Space Cell	0	1	2	3
Straight/Foley Cath Female	Straight/Foley Cath Female: 0	Straight/Foley Cath Female: 1	Straight/Foley Cath Female: 2	Straight/Foley Cath Female: 3
Straight/Foley Cath Male	Straight/Foley Cath Male: 0	Straight/Foley Cath Male: 1	Straight/Foley Cath Male: 2	Straight/Foley Cath Male: 3
Obtain/Instruct Clean Catch Urine	Obtain/Instruct Clean Catch Urine: 0	Obtain/Instruct Clean Catch Urine: 1	Obtain/Instruct Clean Catch Urine: 2	Obtain/Instruct Clean Catch Urine: 3

GASTROINTESTINAL

Space Cell	0	1	2	3
Assess Bowel Sounds	Assess Bowel Sounds: 0	Assess Bowel Sounds: 1	Assess Bowel Sounds: 2	Assess Bowel Sounds: 3
Assess GI Distress/Bleeding	Assess GI Distress/Bleeding: 0	Assess GI Distress/Bleeding: 1	Assess GI Distress/Bleeding: 2	Assess GI Distress/Bleeding: 3
Insertion/Monitoring NG Tube	Insertion/Monitoring NG Tube: 0	Insertion/Monitoring NG Tube: 1	Insertion/Monitoring NG Tube: 2	Insertion/Monitoring NG Tube: 3
Tube Feedings via Flexible Tubes	Tube Feedings via Flexible Tubes: 0	Tube Feedings via Flexible Tubes: 1	Tube Feedings via Flexible Tubes: 2	Tube Feedings via Flexible Tubes: 3
Care of Patient With Abdominal Wounds	Care of Patient With Abdominal Wounds: 0	Care of Patient With Abdominal Wounds: 1	Care of Patient With Abdominal Wounds: 2	Care of Patient With Abdominal Wounds: 3
Care of Patient With Drains	Care of Patient With Drains: 0	Care of Patient With Drains: 1	Care of Patient With Drains: 2	Care of Patient With Drains: 3

CARE OF PSYCHIATRIC DISORDERS

Space Cell	0	1	2	3
Initial Assessment	Initial Assessment: 0	Initial Assessment: 1	Initial Assessment: 2	Initial Assessment: 3
Suicide Risk Assessment	Suicide Risk Assessment: 0	Suicide Risk Assessment: 1	Suicide Risk Assessment: 2	Suicide Risk Assessment: 3
Schizophrenia	Schizophrenia: 0	Schizophrenia: 1	Schizophrenia: 2	Schizophrenia: 3
Paranoid Psychotic Disorder	Paranoid Psychotic Disorder: 0	Paranoid Psychotic Disorder: 1	Paranoid Psychotic Disorder: 2	Paranoid Psychotic Disorder: 3
Catatonic Psychotic Disorder	Catatonic Psychotic Disorder: 0	Catatonic Psychotic Disorder: 1	Catatonic Psychotic Disorder: 2	Catatonic Psychotic Disorder: 3
Hallucinations	Hallucinations: 0	Hallucinations: 1	Hallucinations: 2	Hallucinations: 3
Bipolar Disorder	Bipolar Disorder: 0	Bipolar Disorder: 1	Bipolar Disorder: 2	Bipolar Disorder: 3
Depression	Depression: 0	Depression: 1	Depression: 2	Depression: 3
Suicidal Ideation/Attempts	Suicidal Ideation/Attempts: 0	Suicidal Ideation/Attempts: 1	Suicidal Ideation/Attempts: 2	Suicidal Ideation/Attempts: 3
Delusional Disorders	Delusional Disorders: 0	Delusional Disorders: 1	Delusional Disorders: 2	Delusional Disorders: 3
Anxiety Disorders	Anxiety Disorders: 0	Anxiety Disorders: 1	Anxiety Disorders: 2	Anxiety Disorders: 3
Panic Attacks	Panic Attacks: 0	Panic Attacks: 1	Panic Attacks: 2	Panic Attacks: 3
Phobias	Phobias: 0	Phobias: 1	Phobias: 2	Phobias: 3
Obsessive/Compulsive Disorder	Obsessive/Compulsive Disorder: 0	Obsessive/Compulsive Disorder: 1	Obsessive/Compulsive Disorder: 2	Obsessive/Compulsive Disorder: 3
Dissociative Identity Disorder	Dissociative Identity Disorder: 0	Dissociative Identity Disorder: 1	Dissociative Identity Disorder: 2	Dissociative Identity Disorder: 3
Cluster A - Paranoid/Schizoid	Cluster A - Paranoid/Schizoid: 0	Cluster A - Paranoid/Schizoid: 1	Cluster A - Paranoid/Schizoid: 2	Cluster A - Paranoid/Schizoid: 3
Cluster B - Antisocial/Borderline	Cluster B - Antisocial/Borderline: 0	Cluster B - Antisocial/Borderline: 1	Cluster B - Antisocial/Borderline: 2	Cluster B - Antisocial/Borderline: 3
Cluster C - Anxious/Fearful	Cluster C - Anxious/Fearful: 0	Cluster C - Anxious/Fearful: 1	Cluster C - Anxious/Fearful: 2	Cluster C - Anxious/Fearful: 3
Delirium	Delirium: 0	Delirium: 1	Delirium: 2	Delirium: 3
Dementia	Dementia: 0	Dementia: 1	Dementia: 2	Dementia: 3
Alzheimer's (Dementia)	Alzheimer's (Dementia): 0	Alzheimer's (Dementia): 1	Alzheimer's (Dementia): 2	Alzheimer's (Dementia): 3
Amnestic Disorders	Amnestic Disorders: 0	Amnestic Disorders: 1	Amnestic Disorders: 2	Amnestic Disorders: 3
Anorexia Nervosa	Anorexia Nervosa: 0	Anorexia Nervosa: 1	Anorexia Nervosa: 2	Anorexia Nervosa: 3
Bulimia Nervosa	Bulimia Nervosa: 0	Bulimia Nervosa: 1	Bulimia Nervosa: 2	Bulimia Nervosa: 3
Obesity	Obesity: 0	Obesity: 1	Obesity: 2	Obesity: 3
Alcohol -Related Disorders	Alcohol -Related Disorders: 0	Alcohol -Related Disorders: 1	Alcohol -Related Disorders: 2	Alcohol -Related Disorders: 3
Drug -Related Disorders	Drug -Related Disorders: 0	Drug -Related Disorders: 1	Drug -Related Disorders: 2	Drug -Related Disorders: 3
Sexual Disorders	Sexual Disorders: 0	Sexual Disorders: 1	Sexual Disorders: 2	Sexual Disorders: 3
Sexual Abuse/Assault	Sexual Abuse/Assault: 0	Sexual Abuse/Assault: 1	Sexual Abuse/Assault: 2	Sexual Abuse/Assault: 3
Survivor of Abuse/Violence	Survivor of Abuse/Violence: 0	Survivor of Abuse/Violence: 1	Survivor of Abuse/Violence: 2	Survivor of Abuse/Violence: 3
Post Traumatic Stress Disorder	Post Traumatic Stress Disorder: 0	Post Traumatic Stress Disorder: 1	Post Traumatic Stress Disorder: 2	Post Traumatic Stress Disorder: 3
Somatoform Disorders (Pain etc.)	Somatoform Disorders (Pain etc.): 0	Somatoform Disorders (Pain etc.): 1	Somatoform Disorders (Pain etc.): 2	Somatoform Disorders (Pain etc.): 3
Developmental Disabilities	Developmental Disabilities: 0	Developmental Disabilities: 1	Developmental Disabilities: 2	Developmental Disabilities: 3
ADHD	ADHD: 0	ADHD: 1	ADHD: 2	ADHD: 3

INTERVENTIONS/THERAPIES

Space Cell	0	1	2	3
Crisis Intervention	Crisis Intervention: 0	Crisis Intervention: 1	Crisis Intervention: 2	Crisis Intervention: 3
Therapeutic Communication	Therapeutic Communication: 0	Therapeutic Communication: 1	Therapeutic Communication: 2	Therapeutic Communication: 3
Therapeutic Milieu	Therapeutic Milieu: 0	Therapeutic Milieu: 1	Therapeutic Milieu: 2	Therapeutic Milieu: 3
Education or Vocational Training	Education or Vocational Training: 0	Education or Vocational Training: 1	Education or Vocational Training: 2	Education or Vocational Training: 3
Drug & Alcohol Education	Drug & Alcohol Education: 0	Drug & Alcohol Education: 1	Drug & Alcohol Education: 2	Drug & Alcohol Education: 3
ElectroConvulsive Therapy	ElectroConvulsive Therapy: 0	ElectroConvulsive Therapy: 1	ElectroConvulsive Therapy: 2	ElectroConvulsive Therapy: 3
Crisis Management: Homocide	Crisis Management: Homocide : 0	Crisis Management: Homocide : 1	Crisis Management: Homocide : 2	Crisis Management: Homocide : 3
Crisis Management: Violent Individual	Crisis Management: Violent Individual: 0	Crisis Management: Violent Individual: 1	Crisis Management: Violent Individual: 2	Crisis Management: Violent Individual: 3
Crisis Management: Suicide	Crisis Management: Suicide: 0	Crisis Management: Suicide: 1	Crisis Management: Suicide: 2	Crisis Management: Suicide: 3

PSYCHOTROPIC AGENTS

Space Cell	0	1	2	3
Rapid Tranquilization	Rapid Tranquilization: 0	Rapid Tranquilization: 1	Rapid Tranquilization: 2	Rapid Tranquilization: 3
Antipsychotic Agents	Antipsychotic Agents: 0	Antipsychotic Agents: 1	Antipsychotic Agents: 2	Antipsychotic Agents: 3
Hypnotics	Hypnotics: 0	Hypnotics: 1	Hypnotics: 2	Hypnotics: 3
Antianxiety Agents	Antianxiety Agents: 0	Antianxiety Agents: 1	Antianxiety Agents: 2	Antianxiety Agents: 3
Antidepressants/Mood Elevators	Antidepressants/Mood Elevators: 0	Antidepressants/Mood Elevators: 1	Antidepressants/Mood Elevators: 2	Antidepressants/Mood Elevators: 3
Antimanic Agents	Antimanic Agents: 0	Antimanic Agents: 1	Antimanic Agents: 2	Antimanic Agents: 3
Anticonvulsants	Anticonvulsants: 0	Anticonvulsants: 1	Anticonvulsants: 2	Anticonvulsants: 3
Anticholinergics/Antiparkinsons	Anticholinergics/Antiparkinsons: 0	Anticholinergics/Antiparkinsons: 1	Anticholinergics/Antiparkinsons: 2	Anticholinergics/Antiparkinsons: 3

MEDS SIDE EFFECTS (Recognition/Management)

Space Cell	0	1	2	3
Blurred Vision	Blurred Vision: 0	Blurred Vision: 1	Blurred Vision: 2	Blurred Vision: 3
Constipation	Constipation: 0	Constipation: 1	Constipation: 2	Constipation: 3
Drowsiness	Drowsiness: 0	Drowsiness: 1	Drowsiness: 2	Drowsiness: 3
Dry Mouth	Dry Mouth: 0	Dry Mouth: 1	Dry Mouth: 2	Dry Mouth: 3
Gastrointestinal Effects	Gastrointestinal Effects: 0	Gastrointestinal Effects: 1	Gastrointestinal Effects: 2	Gastrointestinal Effects: 3
Hypo/Hyperglycemia	Hypo/Hyperglycemia: 0	Hypo/Hyperglycemia: 1	Hypo/Hyperglycemia: 2	Hypo/Hyperglycemia: 3
Hypotension/Orthostatic	Hypotension/Orthostatic: 0	Hypotension/Orthostatic: 1	Hypotension/Orthostatic: 2	Hypotension/Orthostatic: 3
Insomnia	Insomnia: 0	Insomnia: 1	Insomnia: 2	Insomnia: 3
Tachycardia	Tachycardia: 0	Tachycardia: 1	Tachycardia: 2	Tachycardia: 3
Urinary Retention	Urinary Retention: 0	Urinary Retention: 1	Urinary Retention: 2	Urinary Retention: 3
Weight Gain	Weight Gain: 0	Weight Gain: 1	Weight Gain: 2	Weight Gain: 3
Parkinsonism Symptoms	Parkinsonism Symptoms: 0	Parkinsonism Symptoms: 1	Parkinsonism Symptoms: 2	Parkinsonism Symptoms: 3
Akathisia (Motor Restlessness)	Akathisia (Motor Restlessness): 0	Akathisia (Motor Restlessness): 1	Akathisia (Motor Restlessness): 2	Akathisia (Motor Restlessness): 3
Acute Dystonic Reactions	Acute Dystonic Reactions: 0	Acute Dystonic Reactions: 1	Acute Dystonic Reactions: 2	Acute Dystonic Reactions: 3
Tardive Dyskinesia	Tardive Dyskinesia: 0	Tardive Dyskinesia: 1	Tardive Dyskinesia: 2	Tardive Dyskinesia: 3
Neuroleptic Malignant Syndrome	Neuroleptic Malignant Syndrome: 0	Neuroleptic Malignant Syndrome: 1	Neuroleptic Malignant Syndrome: 2	Neuroleptic Malignant Syndrome: 3

AGE OF PATIENTS CARED FOR

Space Cell	0	1	2	3
Newborn (birth-30 days)	Newborn (birth-30 days): 0	Newborn (birth-30 days): 1	Newborn (birth-30 days): 2	Newborn (birth-30 days): 3
Infant (30 days - 1 year)	Infant (30 days - 1 year): 0	Infant (30 days - 1 year): 1	Infant (30 days - 1 year): 2	Infant (30 days - 1 year): 3
Toddler (1 - 3 years)	Toddler (1 - 3 years): 0	Toddler (1 - 3 years): 1	Toddler (1 - 3 years): 2	Toddler (1 - 3 years): 3
Preschooler (3 - 5 years)	Preschooler (3 - 5 years): 0	Preschooler (3 - 5 years): 1	Preschooler (3 - 5 years): 2	Preschooler (3 - 5 years): 3
School Age (5 - 12 years)	School Age (5 - 12 years): 0	School Age (5 - 12 years): 1	School Age (5 - 12 years): 2	School Age (5 - 12 years): 3
Adolescents (12 - 18 years)	Adolescents (12 - 18 years): 0	Adolescents (12 - 18 years): 1	Adolescents (12 - 18 years): 2	Adolescents (12 - 18 years): 3
Young Adults (18 - 39 years)	Young Adults (18 - 39 years): 0	Young Adults (18 - 39 years): 1	Young Adults (18 - 39 years): 2	Young Adults (18 - 39 years): 3
Middle Adults (39 - 64 years)	Middle Adults (39 - 64 years): 0	Middle Adults (39 - 64 years): 1	Middle Adults (39 - 64 years): 2	Middle Adults (39 - 64 years): 3
Older Adults (64+ years)	Older Adults (64+ years): 0	Older Adults (64+ years): 1	Older Adults (64+ years): 2	Older Adults (64+ years): 3

1. CANDIDATE SIGNATURE

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