Welcome to Texas Select Staffing!

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
Back Syndromes
Hand Injury
Hip Fractures
Mobilization Techniques
Neck Injuries
Total Hip/Knee Replacement
Total Joint Replacement/Upper Extremities
Transmandibular Joint Dysfunction
NEUROLOGIC	1	2	3	4	1	2	3	4
Head Trauma
Neurosurgery
Spinal Cord Injury
Stroke Rehabilitation
Adaptive Equipment
Functional Splinting
SPORTS MEDICINE	1	2	3	4	1	2	3	4
Biodex
Bracing/Joint Immobilization
Cybex
LIDO
Nautilus/Eagle
Orthotron
Strength & Endurance Training
Taping/Strapping
COMPUTERIZED TESTING	1	2	3	4	1	2	3	4
Fatigue - characteristics
Fiber-type
Functional Strength
Net Muscular Torque
ROM
Work - capacity
OTHER	1	2	3	4	1	2	3	4
Burn Management
Cardiac Rehabilitation
Chest Physiotherapy
Functional Capacity Evaluation
Geriatrics
Inservice Education
Wheelchair/Equipment Assessment
Work Capacity Evaluation
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
MODALITIES/MANUAL SKILLS	1	2	3	4	1	2	3	4
Acuscope
Biofeedback
Continuous Passive Motion Machine
Craniosacral Therapy
Cryotherapy
Diathermy
Electro-acupuncture
Fluidotherapy
Hot/Cold Packs
Hydrotherapy
Hubbard Tank
Therapeutic Pool
Whirlpool
Massage
Muscle Energy Techniques
Muscle Stimulation
Myofascial Release Techniques
Neuro Probe
Paraffin
Spinal Mobilization
Strain/Counter Strain Techniques
TENS
Therpeutic Exercise/Home Programs
Traction
Cervical
Lumbar
Ultrasound
Vasopneumatic Devices
Wound Dressing
PROSTHETICS/ORTHOTICS	1	2	3	4	1	2	3	4
Above Knee Prosthetics
Ankle Foot Orthosis
Below Knee Prosthetics
Dynamic Splints
Gait Analysis
Orthoplast/Aquaplast
Resting Splints
Serial/Inhibitory Casting
Static Splints
Upper Extremity Prosthetics
PEDIATRICS	1	2	3	4	1	2	3	4
Cerebral Palsy
Early Intervention
Equipment Assessment
Activities of Daily Living
Adaptive
Gross Motor Assessment Tools
Learning Disabled
Special Needs Patient
Neurodevelopmental Treatment
Orthotics
Spina Bifida

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.