EXPERIENCE AND SKILLS LEVEL:

Please use the key below for the remainder of this checklist. Check the appropriate box that best describes your skill level in each of the following categories:

A. No Experience

B. Clinical Experience Only

C. Intermittent/Previous Experience Teach

D. Less than 2 Years of Experience

E. 2+ Years of Experience

F. 10+ Years of Experience / Can

AGE SPECIFIC PRACTICE:

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)

Adults

Geriatrics

GENERAL EXPERIENCE > NEUROLOGICAL

Brain Tumor

Cerebral Vascular Accident

Neurodevelopmental Disorders

Parkinson’s

Spasticity Management

Spinal Cord Injury (SCI)

Traumatic Brain Injury (TBI)

GENERAL EXPERIENCE > SPECIALTIES

Aqua Therapy

Burn Management

Craniosacral Therapy

Ergonomic Training

Industrial Rehabilitation

Manual Therapy

Wound Debridement

PEDIATRICS

ADD/ADHD

Asperger’s Syndrome

Autism Spectrum

Behavioral Difficulties

Cerebral Palsy

Cognitively Impaired

Coordination Disorder

Degenerative Disorders

Developmental Delay

Down’s Syndrome

Educational Model/School

Emotionally Impaired

Hearing Impaired

IEP Development

General Weakness

Medical Model/Outpatient

NICU

Orthopedic

Physical Disabilities

Sensory Processing Deficits

Spina Bifida

Visually Impaired

GENERAL WORK SETTING EXPERIENCE:

Please indicate how many years/months of professional work experience you have in each of the following settings. If you do not have any work experience in a category please indicate “0”. Write “C” next to number if experience was solely during your clinical/internship.

Work Setting	Length of Time (in years)
Hospital-General Acute
Hospital-Trauma Acute
Hospital-Sub-Acute
Hospital-Inpatient Rehab
Hospital-Outpatient Neuro
Hospital-Outpatient Ortho
Outpatient-Sports Medicine
NICU
Peds-Inpatient
Peds-Outpatient
Peds-Outpatient Developmental
Early Intervention
Head Start Program
Schools (K-12)
Day Rehab
Home Health - Adults
Home Health - Peds
Industrial Rehab
Workers’ Comp
Fitness Center
Professional Sports
University/College
Research
Long Term Acute Care
Group Homes
Skilled Nursing Facility
Assisted Living
Community Program

I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

EXPERIENCE AND SKILLS LEVEL:

AGE SPECIFIC PRACTICE:

MODALITIES/ TREATMENT TECHNIQUES/ ASSESSMENTS/ EVALUATIONS

GENERAL EXPERIENCE > NEUROLOGICAL

GENERAL EXPERIENCE > ORTHOPEDIC

GENERAL EXPERIENCE > SPECIALTIES

GENERAL EXPERIENCE > OTHER

PEDIATRICS

PEDIATRIC ASSESSMENTS/ EVALUATIONS/ TECHNIQUES:

GENERAL WORK SETTING EXPERIENCE:

Please list any additional skills/training/equipment: