SKILLS & EXPERIENCE INVENTORY
Name:_________________________
Training Program:________________
Date:__________________________
1. Please estimate your previous experience with the following:
| <14 weeks dating US (TAUS/abdominal) | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| <14 weeks dating US (TVUS/intracavitary) | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Options counseling | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Early pregnancy diagnosis | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Ectopic and/or PUL management | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Pelvic exams for pregnancy dating | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| IUD placement | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Contraceptive implant placement | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Diagnosis of miscarriage | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Medical management of miscarriage | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Medication abortion | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Endometrial biopsy | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Cervical dilation | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Electric Vacuum Aspiration (EVA) | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Manual Vacuum Aspiration (MVA) | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Dilation and Evacuation (D&E) | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Management of obstetric hemorrhage | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
2. Please describe any prior experiences that have helped prepare you for this rotation?
3. Why did you decide to participate in this training program?
4. Do you have any hesitations (fears) about participating in this training program or providing abortions?
☐ Yes (please explain) ☐ No
5. Aside from technical skills, what else would you like to gain from this training?
6. Do you anticipate offering procedural abortions in future practice?
☐ Yes ☐ No
7. Do you anticipate offering medication abortion in future practice?
☐ Yes ☐ No
8. Do you anticipate providing care for early pregnancy loss (procedural and/or medication management) in future practice?
☐ Yes ☐ No
9. Is there any other information you would like to provide?