Acute Rehab Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Work Settings	Rating Stars (Click)	1	2	3	4
General Acute Care
Home Health
Nursing Home
Outpatient Clinic
Pediatric Rehab
Acute Rehab Hospital
Rehab Unit in Hospital
Neuro	Rating Stars (Click)	1	2	3	4
Cerebral Vascular Accident
Coma Patients
Head Trauma
Spinal Cord Injury
Parkinson�s Disease
Traumatic Brain Injury
Neuromuscular Disease
Post Craniotomy
Bowl/Bladder Programs