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Occupational Therapy Skills Checklist

Name
Phone Number
Email Address

Please rate your experience / frequency (within the last year) using the following scale
(check the appropriate boxes below):

1 - No Experience / Theory Only
2 - Limited Experience / Need Review
3 - Frequent Experience / May Need Some Review
4 - Experienced / Perform Well

1 - Observed Only / Never Done
2 - Rarely Done (<6 times/year)
3 - Occasionally Done (1 - 2 times/month)
4 - Frequently Done (daily or weekly)

	Experience				Frequency
ORTHOPEDIC	1	2	3	4	1	2	3	4
Arthritis Programs
Energy Conservation
Joint Protection
Hand Injuries
Hip Fractures
Mobilization Techniques
Therapeutic Exercise
Total Hip/Knee Replacement
Total Joint Replacement/Upper Extremities
NEUROLOGICAL	1	2	3	4	1	2	3	4
CVA
Head Trauma
Peripheral Nerve Injuries
Spinal Cord Injury
Adaptive Equipment
Functional Splinting
Wheelchair Evaluation
Stroke Rehabilitation
PSYCHIATRIC	1	2	3	4	1	2	3	4
Acute Disorders
Chronic Disorders
Community Re-entry
Crisis Intervention
Group Treatment
Standardized Assessment Tools
Substance Abuse
PROSTHETICS/ORTHOTICS/FUNCTIONAL TRAINING	1	2	3	4	1	2	3	4
Above Knee Prosthetics
Below Knee Prosthetics
Dynamic Splints
Myofascial Release (MFR)
Orthoplast
Serial/Inhibitory Casting
Static Splints
Upper Extremity Prosthetics
AGE SPECIFIC COMPETENCY	1	2	3	4	1	2	3	4
Newborn/Neonate (birth - 30 days)
Infant (30 days - 1 year)
Toddler (1 - 3 years)
Preschooler (3 - 5 years)
School Age Children (5 - 12 years)
Adolescents (12 - 18 years)
Young Adults (18 - 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)

	Experience				Frequency
ADAPTIVE EQUIPMENT	1	2	3	4	1	2	3	4
Assessment
Fabrication
Functional Activities
ADLs
Home Environment
Pre-discharge Planning
Splinting
Wheelchair
VOCATIONAL TRAINING	1	2	3	4	1	2	3	4
Cognitive Assessment
Functional Capacity Evaluation
Job Task Analysis
Perceptual Assessment
Work Hardening
BTE
Valpar
PEDIATRICS	1	2	3	4	1	2	3	4
Developmental Testing
Discharge Planning (Referral & Resources)
Equipment Assessment
Activities of Daily Living
Wheelchair Positioning Device
Neurodevelopmental Testing
Orthotics
Sensory Integrative Testing
Visual Perceptual Skills Testing
MODALITIES	1	2	3	4	1	2	3	4
Biofeedback
Edema Massage
Feeding Techniques
Fluidotherapy
Muscle Stimulation
Oral Motor Facilities
Paraffin Bath
Therapeutic Pool

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the indivdual completing this form. I hereby authorize Texas Select Staffing to release this Skills Checklist to its client facilities for consideration of employment as a contractor at those facilities.