Clement J. Zablocki Medical Center
5000 West National Ave.
Milwaukee, Wisconsin 53295
Student Nurse Tech – Checklist for Clinical Experience
To the faculty of ________________________________________ School of Nursing:
Your student _______________________________ has applied for a Student Nurse Tech (SNT) position at the
Zablock VA Medical Center. It is the VA policy on Student Nurse Techs they may only perform nursing
procedures they have successfully completed through an approved course of instruction with return
demonstration at their school of training. To assure accuracy of clinical competence and make the best
possible placement for the student we require them to complete the following checklist. Please review their
self-assessment of their clinical practice abilities and sign below to indicate your acknowledgement f its
accuracy. Prospective employees must have this form complete before they begin the interview
process. Your assistance is appreciated.
Clinical Skill
Students
assessment – initial
below each skill you
can perform
independentlyhaving had
experience in clinical
settings
Instructor
assessment- initial
below to concur with
students self
assessment of
competency
Preceptor assessment –
initial below to concur with
students self assessment of
competency
(To be filled in by preceptorafter employment)
Utilizes Standard Precautions
Identifies categories of
isolation
Gathers and documents
diagnostic measurement data
including:
 TPR
 Blood Pressure
 Weight
Blood Glucose Testing
Measures Pulse Oximetry
Measures and records I&O
Provides Activities of Daily
Living (ADLs):
 Feeding patients
 Bathing (bed and
shower)
 Oral hygiene
 Hair Care
Continued on back of page
1
Clinical Skill
Students
assessment – initial
below each skill you
can perform
independentlyhaving had
experience in clinical
settings
Instructor
assessment- initial
below to concur with
students self
assessment of
competency
Preceptor assessment –
initial below to concur with
students self assessment of
competency
(To be filled in by preceptorafter employment)
Insertion of NG tubes –
 Salem Sump
 Levin
 Feeding
Removal of above tubesInsertion of urinary catheters Foley
 Intermittent Cath
Removal of urinary catheters
Application of external urinary
devices
Collects specimens Sputum
 Stool
 Urine
Administration of oxygen
Tracheal Bronchial Toileting
 Oral suction
 Nasal suction
Tracheostomy care
Postural Drainage
Chest Clapping
Dressing changes
 Sterile
 Non-sterile
Application of moist heat
Colostomy care
Bowel Routines (bowel
stimulation for spinal cord
injury patients)
Other skills not listed: (may
use another sheet if
necessary)
I confirm _______________________________ has successfully completed the initialed
clinical skills during her training at our institution.
Signature of Instructor: ______________________________________ date: ______
Signature of Student: ________________________________________ date: ______
2
3