Nursing Skills Survey – From Scratch

The following has all of the text for you to create your own survey using whatever survey tool you like.

Note that, if you create your own, you may have to modify the output to use the other modules we are deploying in the coming days–to avoid that, use our Google Forms templates.

Template text below:

[Insert Your Institution Name] Nursing Skills Survey

Last Name


First Name


Your Primary Clinical Specialty

  • Ambulatory
  • Cardiac Floor
  • Emergency Room
  • General Medicine Floor
  • ICU
  • Labor & Delivery
  • Neuro
  • Oncology
  • Pediatric Floor
  • Perioperative Services
  • Surgical Floor
  • Telemetry
  • Other… Please Specify ________________________________

For the following skill sets or work examples, please indicate your skill level for each domain:

SKILLED: This is a part of your current job, and you are very comfortable performing these actions. (e.g. ICU nurse = titrating vasoactive drips, L+D nurse = Care Peri/Postpartum Patient).

NEED TRAINING: You have done this type of work before, but you would need some training or supervision to feel comfortable; or, this is not something you do every day but that you are willing to perform if necessary.

NOT COMFORTABLE: These are skills or tasks that you are either entirely unfamiliar with (and do not think you could learn in a safe way within 1-2 weeks), or that you would NOT be willing to do for any reason.

Bedside Adult Medicine
General Inpatient Pediatrics
Peri/Postpartum Patients
Ventilated Patients
Management of CRRT
Non-Critical Emergency Dept Patients
Management of IV Infusions
Titrating Vasoactive Drips
Monitoring for Basic Arrhythmias
Participating in Code
ED Triage
Performing ECG
Medication Admnistration
IV Insertion
Foley Insertion
NG/OG placement
ACLS Certification
PALS Certification