Home Health Aide Skills Checklist

Caregiver Name

First NameLast Name

Directions: Please evaluate your HHA strengths and skills using the form below. Mark the appropriate level for each skill:

1. Unfamiliar (No Experience)

2. Familiar (May Require Assistance)

3. Experienced (Performs Independently)

Vital Signs

	1	2	3
Please select the appropriate experience level for each skill.
Temperature - Oral
Temperature - Rectal
Temperature - Axillary
Pulse - Radial
Pulse - Apical
Blood Pressure
Containing Respirations

Personal Care ADL

	1	2	3
Please select the appropriate experience level for each skill.
Bed Bath
Sponge Bath
Tub Bath
Shower
Nail and Skin Care
Hair Care
Oral Hygiene
Brush
Swab
Denture Care
Shave - Razor
Shave - Electric
Assist with Dressing

Elimination

	1	2	3
Please select the appropriate experience level for each skill.
Use of Bed Pan
Bowel Program
Use of Bedside Commode
Measure Urine Output
Empty Foley Catheter Drainage Bag

Safe Transfer Techniques

	1	2	3
Please select the appropriate experience level for each skill.
Range of Motion ROM
Repositioning in Bed
Walker
Hoyer Lift
Assist with Ambulation

Housekeeping Duties

	1	2	3
Please select the appropriate experience level for each skill.
Washing Clothes
Folding Clothes
Dishes
Mop Floors
Dusting
Grocery Shopping/Errands

Meal Preparation

	1	2	3
Please select the appropriate experience level for each skill.
Assist with Feeding
Diabetic Diet
Low Sodium Diet
Special Diet Instructions

Care Experience

	1	2	3
Please select the appropriate experience level for each skill.
Care of Alzheimer Client
Care of Client with Respiratory Difficulties
Care of Client with Stroke
Care of Client with Health Injury
Diabetic Care
Care of the Amputee Client
Care of Bed Bound Client
Care of the Paraplegic or Quadriplegic Client

Client Transportation

	1	2	3
Please select the appropriate experience level for each skill.
Assist in and out of Vehicle
Use of Manual Wheelchair
Use of Electric Wheelchair

I attest that the above checklist evaluating my experience and competency was completed truthfully to the best of my knowledge.

Signature*

Date

MonthDayYear