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Dialysis Tech

Dialysis Tech

  • Date Format: MM slash DD slash YYYY
  • Self-Assessment Rating Scale:

    No Experience
    Theory or observation only during the past 12 months

    Limited Experience
    Performed less than 12 times within the past 12 months and may need a review

    Experienced
    Performed at least once per month within the past 12 months and may need minimal assistance

    Highly Skilled
    Performed on at least a weekly basis over the past 12 months; proficient
  • No ExperienceLimited ExperienceExperienceHighly Skilled
    Acute/Inpatient Dialysis
    Chronic/Outpatient Dialysis
    Dialysis Home Care
    Pediatric Dialysis
    Patient and Family Education
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Bicarbonate Dialysate
    Conductivity Testing
    Priming Dialyzer
    Checks for Machine/Alarm Settings
    Prep Vascular Access
    Local/Topical Skin Anesthesia
    Machine set up w/Anticoagulant
    Collect Blood Specimens
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Volume Status
    Vascular Access Function
    Arterial and Venous
    Blood Flow Rate
    Subjective Response to Treatment
    Management of Anticoagulation
    Conductivity
    Ultrafiltration Calculation
    Operation of Myron L. Meter
    Sequential Ultrafiltration/PUF
    Documentation of Dialysis Treatment
  • No ExperienceLimited ExperienceExperiencedHighly skilled
    Blood Leak Alarm
    Arterial Pressure Alarm
    Venous Pressure Alarm
    Conductivity Alarm
    High temperature Alarm
    Air/foam Detector Alarm
    Power Failure Alarm
    Blood Pump Alarm
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Fistula/Vein Graft
    Return of Blood
    Post Treatment Access Care
    Equipment Clean Up
    Sterilization Procedures
    AV Fistula/AV Graft
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Peritoneal Dialysis
    Hemodialysis
    Tunneled/Non-Tunneled Catheter
    Fluid Overload
    Hypertension
    Hypotension
    Disequilibrium Syndrome
    Hyperkalemia
    Seizures
    Muscle Cramps
    Pyrogenic Reaction
    Hemolysis
    Air Embolus
    Chest Pain
    Anemia
    Neuropathy
    Pericarditis
    Filter blood leak
    Cardiopulmonary arrest
  • No ExperienceLimited ExperienceExperiencedHighly Skilled
    Newborn/Neonate (birth to 30 days)
    Infant (1 month to 1 year)
    Toddler (1 year to 3 years)
    Preschooler (3 years to 5 years)
    School Age Child (5 years to 12 years)
    Adolescents (12 years to 18 years)
    Young Adults (18 years to 39 years)
    Middle Adults (39 to 64 years)
    Geriatric Adults (65+ years)
  • By signing below, I attest that the information contained above is accurate to the best of my knowledge and that I am the individual completing this form. I further authorize the Company to release this Qualification List to the Client facilities in accordance with the consideration of employment as a Healthcare Professional with those facilities.
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