This document contains a survey for a Certified Nurse Midwife assessing her qualifications, experience, and training needs. The nurse's name is provided along with her work and personal phone numbers. She has a current CA RN license and certifications in BLS, NRP, and is up to date on her TB test from September 2011. She is familiar with but has not used the KP Health Connect system and last logged in less than 30 days ago. Her most recent patient assignment was more than 10 years ago in L&D. With orientation and skills validation, she feels competent to practice as an RN in L&D. She requires a refresher on IV skills, IV pumps, Pyxis, and lact

1. TPMG Survey of Non-Union RNs
1) Name: Wilna Marie Roberts
2) What is your position? Certified Nurse Midwife
3) Please provide your work phone number w/area code: 916-474-7271
4) Please let us know the best way to reach you? 530-521-1043
5) Do you have a current CA RN License?
$ Yes
No
6) Please check mark your current certification(s)
Yes No
BLS $
ACLS $
PALS $
PEARS
NRP $
Other (please specify):
7) Are you current on your TB Test?
$ Yes – Please provide most recent TB Test Date: 9/2011
No
8) We would like to know if you are familiar with KP Health Connect.
Yes No
Have you attended training on the use of KP Health Connect? $
Have you used KP Health Connect for nursing documentation? $
9) How long ago did you last log into KPHC?
$ Less than 30 days
More than 30 days
Never
10) Approximately how long ago did you take a patient assignment?
$ Inpatient Outpatient
0 to 1 year ago
1 to 2 years ago
2 to 3 years ago
3 to 5 years ago
5 to 10 years ago

2. $ More than 10 years ago
11) What areas of nursing have you previously worked in?
Please list: L&D
12) With basic orientation and skill competency validation, would you feel competent to
practice as a Registered Nurse?
$ Yes
No
13) In what area(s) of nursing would you feel most competent to practice? (check all that
apply)
ED
GI
14) For which of the following clinical skills/equipment would you require a refresher?
(check all that apply)
Injection Skills
$ IV skills
$ IV pumps
$ Pyxis
$ POCT – lactometer
$ PCOT – iStat
$ Patient handling equipment
$ Medication administration
None of the above
Other (please specify):
15) Which of the following education programs would you need to work in your clinical
area? (check all that apply)
BLS Provider class
BLS Refresher class
$ ACLS Provider class
ACLS Refresher class
PALS Provider class
PALS Refresher class
Clinical Skills Refresher
Other (please specify):
16) Please provide any information you think might be helpful for planning purposes.
Thank you.