CVOR Tech One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreName(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyGeneral SurgeryAbdominal Perineal Resection(Required) 1 2 3 4 Appendectomy/Cholescystectomy(Required) 1 2 3 4 Breast Biopsy(Required) 1 2 3 4 Colon Resection/Surgery(Required) 1 2 3 4 Gastrectomy(Required) 1 2 3 4 Gastric Bypass/Roux-en-Y(Required) 1 2 3 4 Hemorrhoidectomy(Required) 1 2 3 4 Herniorrhaphy(Required) 1 2 3 4 Laparoscopic General Surgeries(Required) 1 2 3 4 Laparoscopic Nissen Fundoplication(Required) 1 2 3 4 Mastectomy(Required) 1 2 3 4 Splenectomy(Required) 1 2 3 4 Thyroidectomy(Required) 1 2 3 4 CardiovascularAorta Repair(Required) 1 2 3 4 Aorto-Bifemoral/Femoral-Pop Bypass(Required) 1 2 3 4 Cardiac Bypass Surgery(Required) 1 2 3 4 Carotid Endarterectomy(Required) 1 2 3 4 Endoscopic Vascular Procedures(Required) 1 2 3 4 Femoral Popliteal Bypass Graft(Required) 1 2 3 4 Laparascopic Cardiac Surgery(Required) 1 2 3 4 Robotic Assisted Cardiac Surgery(Required) 1 2 3 4 Valve Replacement/Repair(Required) 1 2 3 4 Ventricular Assist Device(Required) 1 2 3 4 ThoracicEndoscopic Thoracic Procedures(Required) 1 2 3 4 Esophagogastrectomy(Required) 1 2 3 4 Mediastinotomy/Sternotomy(Required) 1 2 3 4 Thoracoscopy/Nuss Procedure(Required) 1 2 3 4 Thoracotomy(Required) 1 2 3 4 OrthopedicTotal Joint Replacement(Required) 1 2 3 4 Closed Reduction of Fracture(Required) 1 2 3 4 External Fixator(Required) 1 2 3 4 Cannulated Hip Screws(Required) 1 2 3 4 Bankhart Procedure(Required) 1 2 3 4 Birmingham Procedure(Required) 1 2 3 4 Carpal Tunnel Release(Required) 1 2 3 4 Arthroscopy(Required) 1 2 3 4 Anterior Cruciate Ligament(Required) 1 2 3 4 Open Reduction Internal Fixation(Required) 1 2 3 4 NeurologicalCraniotomy(Required) 1 2 3 4 Steriotactic Guided Brain Biopsy(Required) 1 2 3 4 Laminectomy(Required) 1 2 3 4 Laparoscopic Anterior Laminectomy(Required) 1 2 3 4 Insertion of Vagal Nerve Stimulator(Required) 1 2 3 4 Insertion of VP Shunt(Required) 1 2 3 4 Spinal Fusion(Required) 1 2 3 4 Anterior Cervical Discectomy Fusion(Required) 1 2 3 4 Posterior Cervical Laminectomy(Required) 1 2 3 4 GenitourinaryVasicaurethropexy(Required) 1 2 3 4 Marshall Marchetti(Required) 1 2 3 4 Circumcision(Required) 1 2 3 4 Cystoscopy/Cystogram/Pyelogram(Required) 1 2 3 4 Prostatectomy(Required) 1 2 3 4 Nephrectomy(Required) 1 2 3 4 Orchidectomy/Orchidopexy(Required) 1 2 3 4 Ureterostomy(Required) 1 2 3 4 Laparoscopic Assisted GU Procedures(Required) 1 2 3 4 Robotic Assisted GU Procedures(Required) 1 2 3 4 GynecologicalAbdominal Hysterectomy(Required) 1 2 3 4 Anterior Posterior Repair(Required) 1 2 3 4 C-Section(Required) 1 2 3 4 D & C(Required) 1 2 3 4 Laparoscopic Assisted Hysterectomy(Required) 1 2 3 4 Laparotomy with Microtuboplasty(Required) 1 2 3 4 Robotic Assisted GYN Procedures(Required) 1 2 3 4 Vaginal Delivery(Required) 1 2 3 4 Vaginal Hysterectomy(Required) 1 2 3 4 Ear/Nose/ThroatEndoscopic ENT Procedures(Required) 1 2 3 4 Laryngectomy(Required) 1 2 3 4 Mastoidectomy(Required) 1 2 3 4 Myringotomy with Insertion of Tubes(Required) 1 2 3 4 Radical Neck(Required) 1 2 3 4 Septoplasty(Required) 1 2 3 4 Tonsillectomy & Adenoidectomy(Required) 1 2 3 4 Tracheostomy(Required) 1 2 3 4 Tympanoplasty(Required) 1 2 3 4 Craniofacial/Oral/PlasticsCraniectomy(Required) 1 2 3 4 Craniofacial Reconstruction(Required) 1 2 3 4 Dental Surgery(Required) 1 2 3 4 Leforte 1 Maxillary(Required) 1 2 3 4 Sagittal Osteotomy(Required) 1 2 3 4 ORIF Mandibular Fracture(Required) 1 2 3 4 Otoplasty(Required) 1 2 3 4 Reconstruction of Ear(Required) 1 2 3 4 Removal of Arch Bars(Required) 1 2 3 4 Repair of Cleft Lip, Nose, Palate(Required) 1 2 3 4 Rhinoplasty(Required) 1 2 3 4 PlasticBlephoroplasty(Required) 1 2 3 4 Breast Reconstruction with Implant(Required) 1 2 3 4 Breast Reduction Mammoplasty(Required) 1 2 3 4 Face Lift(Required) 1 2 3 4 Mastectomy & Tram Flap Reconstruction(Required) 1 2 3 4 Split Thickness Skin Graft(Required) 1 2 3 4 Suction Lipectomy(Required) 1 2 3 4 TransplantsHeart(Required) 1 2 3 4 Lung(Required) 1 2 3 4 Liver(Required) 1 2 3 4 Pancreas(Required) 1 2 3 4 Eye(Required) 1 2 3 4 Organ Donation(Required) 1 2 3 4 EquipmentElectrocautery (ESU)(Required) 1 2 3 4 Laparoscopy Systems(Required) 1 2 3 4 Neuro(Required) 1 2 3 4 OR Fracture Tables(Required) 1 2 3 4 Orthopedic Total Joint Systems(Required) 1 2 3 4 Power Equipment(Required) 1 2 3 4 Robotics Systems(Required) 1 2 3 4 Spinal Fusion Instrumentation(Required) 1 2 3 4 Other SkillsMalignant Hyperthermia Protocol(Required) 1 2 3 4 Infection Prevention(Required) 1 2 3 4 Isolation Precautions(Required) 1 2 3 4 National Patient Safety Goal(Required) 1 2 3 4 Universal Protocol(Required) 1 2 3 4 Age SpecificNewborn/Neonatal (up to 30 days)(Required) 1 2 3 4 Infant (30 days to 1 year)(Required) 1 2 3 4 Toddler (1 to 3 years)(Required) 1 2 3 4 Preschooler (3 to 5 years)(Required) 1 2 3 4 School Age (5 to 12 years)(Required) 1 2 3 4 Adolescents (12 to 18 years)(Required) 1 2 3 4 Young Adults (18 to 39 years)(Required) 1 2 3 4 Middle Adults (40 to 64 years)(Required) 1 2 3 4 Older Adults (65 & up)(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.
