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Nursing Assistant/ HHA /Caregiver Skills Evaluation 2025 - Self Assessment
Year 2025 - For our records, we would like to keep the most updated skills assessment to better offer you an optimal client match. Please take a few minutes to fill this self evaluation.
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Email *
First Name *
Last Name *
Today's Date
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DD
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YYYY
For the following sections, what is your level of proficiency. A - Never Performed (You have never performed the stated task and have no experience with this type of skill. ) , B - Familiar with (You are familiar with the stated task; but you would need more experience and practice to feel comfortable and proficient in this type of skill. ) , C - Experienced in ( You have performed this task several times; you feel moderately comfortable functioning independently, but you would require are source person to be nearby.), D - Expert (You have a performed this task frequently; you feel comfortable and proficient in this skill; you would not require supervision or practice. )
Personal Care Skills *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Total bed bath
Tub bath
Shower
Sponge bath
Sitz bath
Shampoo
Nail & foot care
Perineal care
Oral care
Denture care
Shave
Assistance with Dressing
Applying Makeup
Activity and Ambulation *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Repositioning
Walk with assistance
Walk with supervision
Walk with gait belt
Up in chair
Dangle
Walker
Passive range of motion
Active range of motion
Transfer
Hoyer lift
Assist with exercise program
Up the bed
Care of Patient Environment *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Linen change
Complete bed change
Cleaning
Elimination *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Monitor bowel movements
Measure output
Bedpan
Bedside commode
Assist to bathroom
Assist with Bowel program
Assist with ostomy change
Empty foley catheter bag
Empty drainage bag
Infection Control *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Universal precautions
TB precautions
Blood borne pathogens
Disposal of hazardous waste
Observation *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Oral
Axillary
Temperature
Rectal
Respiration
Blood pressure
Weight
Other Skills *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Applying clean bandages
Catheter Care
Back rub
Care/Use of Orthotic devices
Applying Antiembolic Stockings
Documentation - Clinical Notes
Documenting ADLs
Nutrition *
A - Never Performed
B - Familiar With
C - Experienced In
D - Expert In
Regular
Low Salt
Low Fat
Bland
Mechanical Soft
Diabetic
Serve Meal
Assist with Feeding
Encouraging Fluids
Fluid Restriction
Other (please list below)
If there are any other caregiving skills that you would like us to know about, please list here. (OPTIONAL)
Please provide examples of a Heart Healthy 3 meal plan AND a 3 Day Meal plan for a Diabetic meal. If you are submitting this survey on your phone, you can send the examples in an email
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