OCCUPATIONAL THERAPY SKILLS CHECKLIST
Name:
When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check mark in box which best describes your expertiese with each skill.

The scale is as follows:
1. Not performed   2. Intermitten experience   3. Very experienced.
ACCREDITING AGENCY
  1. Name of Agency   1 2 3
ADAPTIVE EQUIPMENT
  1. Assessment   1 2 3
    1. Fabrication   1 2 3
      1. Wheelchair   1 2 3
        1. Functional Activities  
          1. Home Environment   1 2 3
          2. A.D.L.s   1 2 3
          3. Pre-discharge Planning   1 2 3
          4. Splinting   1 2 3
        ASSESSMENT & CARE OF PATIENT W/ OR REQUIRING ORTHOPEDIC
        1. Hand Injury   1 2 3
          1. Arthritis Programs   1 2 3
            1. Total Joint Replacement/Upper Extremities   1 2 3
              1. Total Hip/Knee Replacement   1 2 3
                1. Hip Fractures   1 2 3
                  1. Mobilization Techniques   1 2 3
                    CERTIFICATIONS
                    1. BLS   1 2 3
                      1. ACLS   1 2 3
                        EQUIPMENT AND PROCEDURES
                        1. Developmental Disabilities   1 2 3
                          1. Home Accessibility   1 2 3
                            1. Driving Evaluation   1 2 3
                              1. Group Dynamics   1 2 3
                                1. Therapeutic Media   1 2 3
                                  1. Cognitive Retraining   1 2 3
                                    1. Inservice Education   1 2 3
                                      1. Other (Specify)   1 2 3
                                        EXPERIENCE IN PRIMARY AREAS
                                        1. Hospitals   1 2 3
                                          1. Clinics   1 2 3
                                            1. Nursing Homes   1 2 3
                                              1. Home Health   1 2 3
                                                MODALITIES
                                                1. Biofeedback   1 2 3
                                                  1. Muscle Stimulation   1 2 3
                                                    1. Fluidtherapy   1 2 3
                                                      1. Paraffin Bath   1 2 3
                                                        1. Edema Massage   1 2 3
                                                          1. Feeding Techniques   1 2 3
                                                            1. Oral Motor Facilities   1 2 3
                                                              1. Therapeutic Pool   1 2 3
                                                                1. TENS   1 2 3
                                                                  NEUROLOGIC
                                                                  1. Stroke Rehabilitation   1 2 3
                                                                    1. Head Trauma   1 2 3
                                                                      1. Spinal Cord Injury  
                                                                        1. Functional Splinting   1 2 3
                                                                        2. Adaptive Equipment   1 2 3
                                                                        3. Wheelchair Evaluation   1 2 3
                                                                      OTHER
                                                                      1. Work Capacity Evaluation   1 2 3
                                                                      2. Work Hardening  
                                                                        1. BTE   1 2 3
                                                                        2. Valpar   1 2 3
                                                                      3. Job Task Analysis   1 2 3
                                                                      4. Cardiac Rehabilitation   1 2 3
                                                                      5. Burn Management   1 2 3
                                                                      6. Back Injuries   1 2 3
                                                                      PEDIATRICS
                                                                      1. Neurodevelopmental Testing   1 2 3
                                                                      2. Developmental Testing   1 2 3
                                                                      3. Sensory Integrative Testing   1 2 3
                                                                      4. Visual Perceptual Skills Testing   1 2 3
                                                                      5. Orthotics   1 2 3
                                                                      6. Equipment Assessment  
                                                                        1. Wheelchair Positioning Device   1 2 3
                                                                        2. Activities of Daily Living   1 2 3
                                                                      PROSTHETICS/ORTHOTICS/FUNCTIONAL TRAINING
                                                                      1. Above Knee Prosthetics   1 2 3
                                                                        1. Below Knee Prosthetics   1 2 3
                                                                          1. Upper Extremity Prosthetics   1 2 3
                                                                            1. Orthoplast   1 2 3
                                                                              1. Static Splints   1 2 3
                                                                                1. Dynamic Splints   1 2 3
                                                                                  1. Serial/Inhibitory Casting   1 2 3
                                                                                    PSYCHIATRIC
                                                                                    1. Standardized Assessment Tools   1 2 3
                                                                                      1. Group Treatment   1 2 3
                                                                                        1. Substance Abuse   1 2 3
                                                                                          1. Crisis Intervention   1 2 3
                                                                                            1. Acute Disorders   1 2 3
                                                                                              1. Chronic Disorders   1 2 3
                                                                                                1. Community Re-entry   1 2 3
                                                                                                  1. Depression   1 2 3
                                                                                                    VOCATIONAL TRAINING
                                                                                                    1. Perceptual Assessment   1 2 3
                                                                                                      1. Cognitive Assessment   1 2 3
                                                                                                        1. Work Hardening   1 2 3
                                                                                                          1. Functional Capacity Evaluation   1 2 3
                                                                                                            Please list any additional skills, training, or equipment:

                                                                                                            My Experience is primarily in Number of Years
                                                                                                            General Acute Care
                                                                                                            Rehab Clinic
                                                                                                            Rehabilitation Hospital
                                                                                                            Children’s Hospital
                                                                                                            School System
                                                                                                            Home Health Care
                                                                                                            Outpatient Clinic
                                                                                                            Skilled Nursing Facility
                                                                                                            Industrial Medicine
                                                                                                            Psychiatric Hospital
                                                                                                            Work Hardening
                                                                                                            Other

                                                                                                            BCLS Certification   Expiration Date
                                                                                                            The information I have given is true and accurate to the best of my knowledge. Please sign and date below.
                                                                                                            SIGNATURE: (Last 4 digits of your SSN)    Reenter your last 4 digits of your SSN:   DATE:

                                                                                                              
                                                                                                            Email:jobs@staffhospital.com  P.O.Box 225216 S.F. CA 94122 Tel:(866)713-4405 Fax:(866)232-3799
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