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Occupational Therapist Skills Checklist

Please fill out and submit the online Skills Checklist below.

You can also click here to download a PDF version of this form to fill out offline, and mail or fax it to us.
Mail: Prime HealthCare Staffing - 27240 Haggerty Road, Suite E-15 - Farmington Hills MI 48331
Toll Free Fax: 866-992-0900

First Name:
Last Name:
Please indicate how many years/months of professional work experience you have in the following settings.
If you have no work experience in a category please indicate 0. If experience was in your clinicals/internship ONLY, indicate C.


GENERAL WORK SETTING EXPERIENCE
Setting Length

Setting

 Length Setting Length Setting Length
Hospital-General Acute NICU Sports Medicine University /College
Hospital-Trauma Acute Peds-Inpatient Home Health Adults Research
Hospital-Sub-acute PedsOutpatient Ortho Home Health Peds Long Term Acute Care
Hospital-Inpatient Rehab Peds-Outpatient Developmental Industrial Rehab Group Homes
Hospital-Outpatient Neuro Early Intervention Workers' Comp Skilled Nursing Facility
Hospital-Outpatient Ortho Headstart Program Community Program Assisted Living
Hospital-Psychiatric Schools (K-12) Law Offices Hospice

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 D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


AGE SPECIFIC PRACTICE
AREA A B C D E F AREA A B C D E F
Newborn (birth-30 days) School Age (5-12 years)
Infant (30 days-1 year) Adolescents (12-18 years)
Toddler (1-3 years) Adults
Preschooler (3-5 years) Geriatrics

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


GENERAL EXPERIENCE
NEUROLOGICAL A B C D E F PSYCHIATRIC A B C D E F
Brain Tumor Acute Psyche
Cerebral Vascular Accident (CVA) Anger Management
Neurodevelopmental Disorders Chronic Psyche
Parkinson's Community Re-entry
Spasticity Management Crisis Intervention
Spinal Cord Injury (SCI) Stress Management
Traumatic Brain Injury (TBI) Substance Abuse
ORTHOPEDIC A B C D E F OTHER A B C D E F
Arthritis AIDS/HIV
Elbow Injuries Amputee
Fractures Aqua Therapy
Hands-Nerve Injury Burn Management
Hands-Tendon Repair Cardiac Rehabilitation
Osteoporosis Chronic Obstructive Pulmonary Disorder
Prosthetics Fitting and Training Cognitive Rehabilitation
Repetitive Injuries Education-Family
Shoulder Injuries Education-Patient
Splints-Dynamic Industrial Rehabilitation/Workers' Comp
Splints-Static Prevocational Training
Sports Injuries PPS
Total Hip Arthroplasty (THA) RUGS
Total Knee Arthroplasty (TKA) Student Supervision
Wrist Injuries Vent/Trache

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


MODALITIES/TREATMENT TECHNIQUES/ASSESMENTS/EVALUATIONS
AREA A B C D E F AREA A B C D E F
Adaptive Equipment Lymphedema
Biofeedback Manual Therapy
BTE Muscle Stimulation
Cognitive Assessment Myofascial Release
Cognitive ReTraining NDT
Contrast Bath Oral Motor
Craniosacral Paraffin Bath
Cryotherapy Perceptual Assessment
Edema Massage Standardized Tests
Energy Conservation TENS
Feeding Techniques Ultrasound
Fluidotherapy Valpar
Hot/Cold Packs Visual Motor
Hydrotherapy Work Capacity Evaluation
Joint Mobilization Wound Debridement

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


PEDIATRIC EXPERIENCE
AREA A B C D E F AREA A B C D E F
ADD/ADHD General Weakness
Asperger's Syndrome Hearing Impaired
Autism Spectrum IEP Development
Behavioral Difficulties Learning Disabilities
Cerebral Palsy Medical Model/Private Practice/Outpatient
Cognitively Impaired NICU Treatment
Coordination Disorder Orthopedic
Degenerative Disorders Physical Disabilities
Developmental Delay Sensory Processing Deficits/Sensory Motor
Down's Syndrome Spina Bidfida
Educational Model/Schools Visual Motor/Perceptual Difficulties
Emotionally Impaired Visually Impaired

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


PEDIATRIC ASSESSMENTS/EVALUATIONS/TECHNIQUES
AREA A B C D E F AREA A B C D E F
Feeding Techniques Sensory Integration
Handwriting Assessments SIPT
Neurodevelopmental Techniques (NDT) Splinting / Orthotics
Oral Motor Standardized Testing
Orthopedic Assessments Visual Motor Testing
Orthopedic Treatments Visual Perceptual Testing
Pediatric Adaptive Equipment Wheelchair Assessments
A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach

Please list any special certifications you have, and skills or comments that you feel would help us find the proper placement for you.
Please read the following before submitting this survey
I verify that this statement of my work experience is accurate to the best of my knowledge.

I give my permission to Prime HealthCare Staffing to use this information while making appropriate job placements for me.
I understand this may include releasing this information to potential customers, upon request, during the assignment process.

I have read and agree to the above statements.