SKILLS & EXPERIENCE INVENTORY
Name:
Training Program:
1. Please estimate your previous experience with the following procedures:
| 1st trimester ultrasound dating | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Pelvic exams for dating | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| IUD insertion | ☐ None | ☐ 1-4 | ☐ 5-10 | ☐ 11-20 | ☐ >20 |
| Contraceptive implant insertion | ☐ 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 |
2. Please describe any prior experiences that have helped prepare you for this rotation?
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3. Provide three reasons why you decided to participate in this training program?
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4. Do you have any hesitations (fears) about participating in this training program or providing abortions? (If so, please explain)
☐ Yes ☐ No
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5. Aside from technical skills, what else would you like to gain from this training?
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6. Do you anticipate offering procedural abortions in future practice? ☐ Yes ☐ No
7. Do you anticipate offering medication abortion or management for early pregnancy loss in future practice?
☐ Yes ☐ No