Your name
Your Email
Last 4 Of SSN
Date
E-Signature
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.
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Work Settings
General acute care: 0★★★★−
Adult/adult ICU: 0★★★★−
Pediatrics/PICU: 0★★★★−
Children's hospital: 0★★★★−
Hand therapy: 0★★★★−
Home health care: 0★★★★−
Outpatient neuro: 0★★★★−
Outpatient ortho: 0★★★★−
Psychiatric hospital: 0★★★★−
Rehabilitation hospital/inpatient rehabilitation unit: 0★★★★−
Skilled care facility: 0★★★★−
School setting: 0★★★★−
Early intervention: 0★★★★−
Subacute: 0★★★★−
Orthopedics
Hand injury: 0★★★★−
Total joint replacement/upper extremities: 0★★★★−
Lower back/spinal surgeries: 0★★★★−
Arthritis programs: 0★★★★−
Soft tissue injuries: 0★★★★−
Knee injuries & total knee replacement: 0★★★★−
Hip fractures & total hip replacement: 0★★★★−
Mobilization techniques: 0★★★★−
Prosthetics/amputations: 0★★★★−
Neurologic
Alzheimers/dementia: 0★★★★−
Degenerative diseases of the CNS: 0★★★★−
Multiple sclerosis: 0★★★★−
Parkinson's disease: 0★★★★−
Spinal cord injury: 0★★★★−
Adaptive equipment: 0★★★★−
Neurodevelopmental testing (NDT): 0★★★★−
Wheelchair evaluation: 0★★★★−
Stroke acute: 0★★★★−
Stroke rehabilitation: 0★★★★−
Functional splinting: 0★★★★−
Traumatic brain injury: 0★★★★−
Pediatric Assessments
Neurodevelopmental testing: 0★★★★−
Developmental screening: 0★★★★−
Sensory-motor testing: 0★★★★−
Visual perceptual testing: 0★★★★−
Feeding/swallowing/oral motor: 0★★★★−
Seating & positioning assessment (i.e. w/c): 0★★★★−
Other Assessments
Physical capacity evaluation: 0★★★★−
Home assessments/home accessibility: 0★★★★−
Activities of daily living: 0★★★★−
Driving evaluation: 0★★★★−
Cognitive/perception: 0★★★★−
Treatment Approaches
ADL: 0★★★★−
Cognitive retraining: 0★★★★−
Community re-entry: 0★★★★−
Energy conservation/work simplification techniques: 0★★★★−
Functional transfer training: 0★★★★−
Home safety: 0★★★★−
Lymphedema management: 0★★★★−
Orthotics/Prosthetics training: 0★★★★−
Patient, family & staff training: 0★★★★−
PNF: 0★★★★−
SI: 0★★★★−
Therapeutic exercises/activities: 0★★★★−
Work hardening: 0★★★★−
Splinting: 0★★★★−
Incontinence management: 0★★★★−
Modalities
Anodyne: 0★★★★−
Biofeedback: 0★★★★−
Electrical stimulation: 0★★★★−
Feeding techniques: 0★★★★−
Fluidotherapy: 0★★★★−
Oral motor facilities: 0★★★★−
Paraffin bath: 0★★★★−
TENS: 0★★★★−
Therapeutic pool: 0★★★★−
Ultrasound: 0★★★★−
Prosthetics/Orthotics
UE prosthetics: 0★★★★−
Static splints: 0★★★★−
Dynamic splints: 0★★★★−
Serial casting: 0★★★★−
Other
Burn management: 0★★★★−
Cardiac rehabilitation: 0★★★★−
Computer skills: 0★★★★−
FIM scoring: 0★★★★−
Geriatrics: 0★★★★−
Group dynamics: 0★★★★−
IEP skills: 0★★★★−
Inservice education: 0★★★★−
Job task analysis: 0★★★★−
Therapeutic media: 0★★★★−
Knowledge of payment sources: 0★★★★−
Medicare: 0★★★★−
Medicaid: 0★★★★−
MDS: 0★★★★−
General Skills
Patient/family teaching: 0★★★★−
Patients in isolation: 0★★★★−
Patients in restraints: 0★★★★−
Initial evaluation: 0★★★★−
Lift/transfer devices: 0★★★★−
Specialty beds: 0★★★★−
End of life care/palliative care: 0★★★★−
Computerized Charting:
Cerner: 0★★★★−
EPIC: 0★★★★−
McKesson: 0★★★★−
Meditech: 0★★★★−
National Patient Safety Goals:
Accurate patient identification: 0★★★★−
Effective communication: 0★★★★−
Pain assessment & management: 0★★★★−
Infection control: 0★★★★−
Universal precautions: 0★★★★−
Care of patients in isolation: 0★★★★−
Minimize risk of falls: 0★★★★−
Prevention of pressure ulcers: 0★★★★−
Age Specific Competencies
Infant (birth to 1 year): 0★★★★−
Toddler (ages 1-3 years): 0★★★★−
Preschooler (ages 3-5 years): 0★★★★−
Childhood (ages 6-12 years): 0★★★★−
Adolescents (ages 12-21 years): 0★★★★−
Young Adults (ages 21-39 years): 0★★★★−
Adults (ages 40-64 years): 0★★★★−
Older Adults (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
Please list any Additional Skills
Additional training:
Additional equipment:
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