OT Skills Checklist

Please complete this checklist as accurately as possible to help MAS Medical uncover your areas of expertise.

The Purpose of this checklist is to more clearly outline the Occupational Therapist's areas of expertise. Please complete this checklist as accurately as possible.
Today's Date*
First Name*
Last Name*
Email Address*
Certifications and Expiration Date
If none, please put n/a.
BCLS*
ACLS*
CPR*
Other*
Other*
State OT Licenses and Expiration*
Please indicate your level of experience.

A. ORTHOPEDICS
Arthritis Program*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Therapeutic Exercise*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
a. Energy Conservation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
b. Joint Protection*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Hip Fractures*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Mobilization Techniques*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Total Hip/ Total Knee Replacement*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
B. NEUROLOGIC
Head Trauma*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Spinal Cord Injuries*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
CVA Rehabilitation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Stroke Rehabilitation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
a. Functional Splinting*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
b. Adaptive Equipment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
c. Wheel Chair Evaluation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Peripheral Nerve Injuries*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Cognitive Retraining*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Parkinson's Disease*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
C. MODALITIES/MANUAL SKILLS
Above Knee Prosthetics*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Below Knee Prosthetics*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Myofacial Release*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Gait Analysis*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Orthoplast/ Aquaplast*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Serial/Inhibitory Casting*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Upper Extremity Prosthetics*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Lower Extremity Prosthetic*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Dynamic Splints*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Static Splints*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Functional Splinting*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
E. PEDIATRICS
Cerebral Palsy*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Autism*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Down's Syndrome*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Neurodevelopment Testing/ Treatment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Sensory Integrated Testing/ Treatment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Developmental Testing/ Treatment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Visual Perceptual Testing/ Treatment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
NICU Treatment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Discharge Planning*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Equipment Assessment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
a. Activities of Daily Living (ADL's)*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
b. Wheelchair Positioning Device*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Learning Disabilities*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Early Intervention*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Orthotics*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
F. ADAPTIVE EQUIPMENT
Assessment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Fabrication*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Functional Activities*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
a. Activities of Daily Living (ADL's)*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
b. Home Environment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
c. Pre Discharge Planning*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
d. splinting*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Wheelchair*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
G. VOCATIONAL TRAINING
Cognitive Assessment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Functional Capacity Evaluation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Job Task Analysis*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Perceptual Assessment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Work Hardening*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
a. BTE*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
b. Valpar*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
H. OTHER
Burn Management*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Cardiac Rehabilitation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Chest Rehabilitation*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
In-service Education*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
Wheelchair/Equipment Assessment*
Theory, No Practice Intermittent Experience 1-2 Years of Experience More Than 2 Years of Experience
EXPERIENCE WITH AGE GROUPS
Able to adapt care to incorporate normal growth and development.*
- Neo-Natal
- Peds
- Adolescent
- Adult
- Geriatrics
Able to adapt method and terminology of patient instruction to age, comprehension and maturity level.*
- Neo-Natal
- Peds
- Adolescent
- Adult
- Geriatrics
Able to ensure a safe environment reflecting specific needs of age group.*
- Neo-Natal
- Peds
- Adolescent
- Adult
- Geriatrics
TOTAL YEARS OF EXPERIENCE WITH SETTINGS
General Acute Care*
Rehabilitation Hospital*
Home Health*
Long Term Care*
Nursing Home*
Out Patient Clinic*
Pediatric Rehabilitation*
Industrial Setting*
School System*
Confirmation*
- I attest that the information I have provided is true and accurate to the best of my knowledge.
I am the individual completing this form. By checking this box I authorize MAS Medical Staffing to release this checklist to client facilities in consideration for employment.

Certifications and Expiration Date

A. ORTHOPEDICS

B. NEUROLOGIC

C. MODALITIES/MANUAL SKILLS

E. PEDIATRICS

F. ADAPTIVE EQUIPMENT

G. VOCATIONAL TRAINING

H. OTHER

EXPERIENCE WITH AGE GROUPS

TOTAL YEARS OF EXPERIENCE WITH SETTINGS