Occupational Therapy Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWork SettingsGeneral acute care 1 2 3 4 Adult/adult ICU 1 2 3 4 Pediatrics/PICU 1 2 3 4 Children’s hospital 1 2 3 4 Hand therapy 1 2 3 4 Home health care 1 2 3 4 Outpatient neuro 1 2 3 4 Outpatient ortho 1 2 3 4 Psychiatric hospital 1 2 3 4 Rehabilitation hospital/inpatient rehabilitation unit 1 2 3 4 Skilled care facility 1 2 3 4 School setting 1 2 3 4 Early intervention 1 2 3 4 Subacute 1 2 3 4 OrthopedicsHand injury 1 2 3 4 Total joint replacement/upper extremities 1 2 3 4 Lower back/spinal surgeries 1 2 3 4 Arthritis programs 1 2 3 4 Soft tissue injuries 1 2 3 4 Knee injuries & total knee replacement 1 2 3 4 Hip fractures & total hip replacement 1 2 3 4 Mobilization techniques 1 2 3 4 Prosthetics/amputations 1 2 3 4 NeurologicAlzheimers/dementia 1 2 3 4 Degenerative diseases of the CNS 1 2 3 4 Multiple sclerosis 1 2 3 4 Parkinson’s disease 1 2 3 4 Spinal cord injury 1 2 3 4 Adaptive equipment 1 2 3 4 Neurodevelopmental testing (NDT) 1 2 3 4 Wheelchair evaluation 1 2 3 4 Stroke acute 1 2 3 4 Functional splinting 1 2 3 4 Traumatic brain injury 1 2 3 4 Pediatric AssessmentsNeurodevelopmental testing 1 2 3 4 Developmental screening 1 2 3 4 Sensory-motor testing 1 2 3 4 Visual perceptual testing 1 2 3 4 Feeding/swallowing/oral motor 1 2 3 4 Seating & positioning assessment (i.e. w/c) 1 2 3 4 Other AssessmentsPhysical capacity evaluation 1 2 3 4 Home assessments/home accessibility 1 2 3 4 Activities of daily living 1 2 3 4 Driving evaluation 1 2 3 4 Cognitive/perception 1 2 3 4 Treatment ApproachesADL 1 2 3 4 Cognitive retraining 1 2 3 4 Community re-entry 1 2 3 4 Energy conservation/work simplification techniques 1 2 3 4 Functional transfer training 1 2 3 4 Home safety 1 2 3 4 Lymphedema management 1 2 3 4 Orthotics/Prosthetics training 1 2 3 4 Patient, family & staff training 1 2 3 4 PNF 1 2 3 4 SI 1 2 3 4 Therapeutic exercises/activities 1 2 3 4 Work hardening 1 2 3 4 Splinting 1 2 3 4 Neurodevelopmental testing (NDT) 1 2 3 4 Incontinence management 1 2 3 4 ModalitiesAnodyne 1 2 3 4 Biofeedback 1 2 3 4 Electrical stimulation 1 2 3 4 Feeding techniques 1 2 3 4 Fluidotherapy 1 2 3 4 Oral motor facilities 1 2 3 4 Paraffin bath 1 2 3 4 TENS 1 2 3 4 Therapeutic pool 1 2 3 4 Ultrasound 1 2 3 4 Prosthetics/OrthoticsUE prosthetics 1 2 3 4 Static splints 1 2 3 4 Dynamic splints 1 2 3 4 Serial casting 1 2 3 4 OtherBurn management 1 2 3 4 Cardiac rehabilitation 1 2 3 4 Cognitive retraining 1 2 3 4 Computer skills 1 2 3 4 FIM scoring 1 2 3 4 Geriatrics 1 2 3 4 Group dynamics 1 2 3 4 IEP skills 1 2 3 4 Inservice education 1 2 3 4 Job task analysis 1 2 3 4 Therapeutic media 1 2 3 4 Knowledge of payment sources 1 2 3 4 Medicare 1 2 3 4 Medicaid 1 2 3 4 MDS 1 2 3 4 General SkillsPatient/family teaching 1 2 3 4 Patients in isolation 1 2 3 4 Patients in restraints 1 2 3 4 Lift/transfer devices 1 2 3 4 Specialty beds 1 2 3 4 End of life care/palliative care 1 2 3 4 Computerized ChartingCerner 1 2 3 4 EPIC 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 National Patient Safety GoalsAccurate patient identification 1 2 3 4 Effective communication 1 2 3 4 Pain assessment & management 1 2 3 4 Infection control 1 2 3 4 Universal precautions 1 2 3 4 Care of patients in isolation 1 2 3 4 Minimize risk of falls 1 2 3 4 Prevention of pressure ulcers 1 2 3 4 Age Specific CompetenciesInfant (birth to 1 year) 1 2 3 4 Toddler (ages 1-3 years) 1 2 3 4 Preschooler (ages 3-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 12-21 years) 1 2 3 4 Young Adults (ages 21-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adult (ages 65-79 years) 1 2 3 4 Elderly (80+ years) 1 2 3 4 Additional SkillsPlease list any additional skillsAdditional TrainingPlease list any additional trainingAdditional EquipmentPlease list any additional equipmentAuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Occupational Therapy Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
