Occupational Therapy Skills Checklist 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
Adult/adult ICU
Pediatrics/PICU
Children�s hospital
Hand therapy
Home health care
Outpatient neuro
Outpatient ortho
Psychiatric hospital
Rehabilitation hospital/inpatient rehabilitation unit
Skilled care facility
School setting
Orthopedics	Rating Stars (Click)	1	2	3	4
Alzheimers/dementia
Degenerative diseases of the CNS
Multiple sclerosis
Parkinson�s disease
Spinal cord injury
Adaptive equipment
Neurodevelopmental testing (NDT)
Wheelchair evaluation
Stroke acute
Neurologic	Rating Stars (Click)	1	2	3	4
Alzheimers/dementia
Degenerative diseases of the CNS
Multiple sclerosis
Parkinson�s disease
Spinal cord injury
Adaptive equipment
Neurodevelopmental testing (NDT)
Wheelchair evaluation
Stroke acute
Pediatric Assessments	Rating Stars (Click)	1	2	3	4
Neurodevelopmental testing
Developmental screening
Sensory-motor testing
Visual perceptual testing
Feeding/swallowing/oral motor
Seating & positioning assessment (i.e. w/c)