Skills Checklist - OT/COTA - Origin Travel Nurses

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

Age Group Experience*

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
MM slash DD slash YYYY

Origin Travel Nurses has earned the Joint Commission's Gold Seal of Approval

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Fractures
Total Joint Replacements
Osteoarthritis-Frozen Shoulder
Hand Injuries
Post Operative Care
Amputations

	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