Skills Checklist – OT/COTA Skills Checklist – OT/COTA Name First Last Phone Email SETTING* Rarely Some Experience Proficient Trainer / Preceptor N/A Acute Rehab Inpatient Outpatient Home Health SNF Schools ADULT – ORTHOPEDIC* Rarely Some Experience Proficient Trainer / Preceptor N/A Fractures Total Joint Replacements Osteoarthritis-Frozen Shoulder Hand Injuries Post Operative Care Amputations ADULT – Neurologic:* Rarely Some Experience Proficient Trainer / Preceptor N/A Stroke Rehabilitation Cognitive Disorders Head Trauma Spinal Cord Injury Neuromuscular Diseases Alzheimer’s/Dementia Adaptive Equipment-Wheelchair ADULT – Prosthetics / Orthotics:* Rarely Some Experience Proficient Trainer / Preceptor N/A Upper Extremity Prosthetics ADULT – Procedures / Treatments:* Rarely Some Experience Proficient Trainer / Preceptor N/A Splinting – Wrist Splinting – Hand Splinting – Elbow Functional – Dynamic Splinting Adaptive Equipment Joint Mobilization Myofacial Release Soft Tissue Manipulation Iontophoresis TENS Hydrotherapy – Whirlpool Sterilization Techniques Cryotherapy Wound Management Debridement Ultrasound Phonophoresis Cognitive Techniques Vision Therapy Neurodevelopmental Techniques Adaptive Equipment Assessment Adaptive Equipment Training Feeding Techniques Exercise Programs Postural Education Home Safety Evaluation Community Re-entry Group Treatment GERIATRIC – Skilled Nursing Documentation:* Rarely Some Experience Proficient Trainer / Preceptor N/A Medicare A Medicare B State Healthcare GERIATRIC – Other:* Rarely Some Experience Proficient Trainer / Preceptor N/A Cardiac Rehab ICU Procedures CCU Procedures SICU Procedures Burn Management Work Hardening – Work Site Eval Functional Capacity Eval Transfers Gait Training Muscle Energy Techniques Activities of Daily Living Electronic Documentation GERIATRIC – OTHER – TYPES OF ELECTRONIC DOCUMENTATION:(if applicable) Age Group Experience* Rarely Some Experience Proficient Trainer / Preceptor N/A Newborn (birth – 30 days) Infant (30 days – 1 year) Toddler (1 – 3 years) Preschooler (3 – 5 years) School Age (5 – 12 years) Adolescents (12 – 18 years) Young Adults (18 – 39 years) Middle Adults (39-64 years) Older Adults (64+ years) Do you speak any languages other than English?* No If yes, enter languages above, separated by commas. Confirmation* I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education. Signature Date Date Format: MM slash DD slash YYYY