Instructions:

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

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/ Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    SETTINGS
    Acute Care/ Hospital
    Sub Acute
    Rehabilitation - Acute
    Rehabilitation - Long Term
    Home Health
    Outpatient
    Adults/ Adult ICU
    Pediatrics/PICU/NICU
    Psychiatric Hospital
    Skilled Nursing Facility
    School Setting
    Early Intervention
    NEUROLOGICAL
    Adaptive Equipment
    Alzheimer's/Dementia
    CVA
    Degenerative Diseases of the CNS
    Functional Splinting
    Head Trauma
    Peripheral Nerve Injuries
    Multiple Sclerosis
    Parkinson's Disease
    Spinal Cord Injury
    Stroke Rehabilitation
    Traumatic Brain Injury
    Wheelchair Evaluation
    Neurodevelopmental testing (NDT)
    ORTHOPEDICS
    Arthritis Programs
    Joint protection
    Hip Fractures
    Mobilization Techniques
    Total Joint Replacements upper extremities
    Total Knee/Hip Replacement
    Lower back/spinal surgery
    Soft tissue Injury
    Prosthetics/amputations
    PEDIATRICS
    Developmental Testing
    Neurodevelopmental testing (NDT)
    Feeding/swallowing/oral motor
    Equipment Assessment
    Orthotics
    Sensory Integrative Testing
    Visual Perceptual Skills Testing
    Wheelchair Positioning Device
    Muscular Dystrophy
    Cerebral Palsy
    Cystic Fibrosis
    Birth Defects
    PROSTHETICS/ORTHOTICS
    Above/Below Knee Prosthetics
    Dynamic Splints
    UE Prosthetics
    Orthoplast
    Serial/inhibitory Casting
    Static Splints
    ADAPTIVE EQUIPMENT
    Assessment
    Fabrication
    Functional Activities:
    ADL's
    Home Environment
    Pre-discharge Planning
    Splinting
    Wheelchair
    VOCATIONAL TRAINING
    Cognitive Assessment
    Functional Capacity Evaluation
    Job Task Analysis
    Perceptual Assessment
    Work Hardening
    BTE
    Valpar
    MODALITIES
    Anodyne
    Biofeedback
    Community Re-Entry
    Feeding Techniques
    Fluidotherapy
    Gait Training
    Massage
    Muscle Stimulation
    Oral Motor Facilities
    Paraffin Bath
    TENS
    Therapeutic Pool
    Ultrasound
    Wound Management
    GENERAL SKILLS
    Electronic Documentation
    Other Electronic Documentation:
    Universal Precautions
    Working with patients in isolation
    Working with patients in restraints
    Patient/Family teaching
    Patient Identification
    Specialty beds
    End of life care/palliative care
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores