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Rehab Skills Checklist

My responses in this checklist represent a true reflection of my experience and comfort level. Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.

* Typed Name (typing your name below serves as an electronic signature)

* Phone Number

* Email

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Certifications: (Check all that apply)

BLS/BCLS/CPR
CRRN

Level of Comfort/Experience

N/A=Non-applicable
1=Inexperienced in this area
2=Limited comfort/experience in this area
3=Comfortable/experienced in this area
4=Very comfortable/highly experienced in this area

Work Settings	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
General Acute Care	N/A	1	2	3	4
Home Health	N/A	1	2	3	4
Nursing Home	N/A	1	2	3	4
Outpatient Clinic	N/A	1	2	3	4
Pediatric Rehab	N/A	1	2	3	4
Acute Rehab Hospital	N/A	1	2	3	4
Rehab Unit in Hospital	N/A	1	2	3	4
Neuro	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Cerebral Vascular Accident	N/A	1	2	3	4
Coma Patients	N/A	1	2	3	4
Head Trauma	N/A	1	2	3	4
Spinal Cord Injury	N/A	1	2	3	4
Parkinson's Disease	N/A	1	2	3	4
Traumatic Brain Injury	N/A	1	2	3	4
Neuromuscular disease	N/A	1	2	3	4
Post Craniotomy	N/A	1	2	3	4
Bowel/Bladder programs	N/A	1	2	3	4
Ortho	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Arthritis Programs	N/A	1	2	3	4
Back Syndrome	N/A	1	2	3	4
Cervical Traction	N/A	1	2	3	4
Continuous Passive Motion Machine N/A	N/A	1	2	3	4
Gait Training	N/A	1	2	3	4
Hand Injury	N/A	1	2	3	4
Hip Fractures	N/A	1	2	3	4
Care of Patient with Halo	N/A	1	2	3	4
Hot/Cold Packs	N/A	1	2	3	4
Mobilization Techniques	N/A	1	2	3	4
Neck Injuries	N/A	1	2	3	4
TMJ Dysfunction	N/A	1	2	3	4
Total Hip Replacement	N/A	1	2	3	4
Total Knee Replacement	N/A	1	2	3	4
Pulmonary	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Assessment of breath sounds	N/A	1	2	3	4
Chest Physiotherapy	N/A	1	2	3	4
Oximetry	N/A	1	2	3	4
Nasal cannula	N/A	1	2	3	4
Face Mask	N/A	1	2	3	4
Portable O2 tank	N/A	1	2	3	4
Nasotracheal Suctioning	N/A	1	2	3	4
Tracheal Suctioning	N/A	1	2	3	4
Care of patient w/Mechanical Vent	N/A	1	2	3	4
COPD	N/A	1	2	3	4
Pediatrics	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Cerebral Palsy	N/A	1	2	3	4
Activities of Daily Living	N/A	1	2	3	4
Learning Disabilities	N/A	1	2	3	4
Orthotics	N/A	1	2	3	4
Spina Bifida	N/A	1	2	3	4
Autism	N/A	1	2	3	4
AK Prosthetics	N/A	1	2	3	4
Amputees	N/A	1	2	3	4
BK Prosthetics	N/A	1	2	3	4
Bracing/ Joint Immobilization	N/A	1	2	3	4
Resting Splints	N/A	1	2	3	4
Casts/check for circulation	N/A	1	2	3	4
Upper Extremity Prosthetics	N/A	1	2	3	4
Nutritional Requirements	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Thickened Liquids	N/A	1	2	3	4
Minimal	N/A	1	2	3	4
Thick	N/A	1	2	3	4
Extra Thick	N/A	1	2	3	4
Pudding Thick	N/A	1	2	3	4
NG Tubes	N/A	1	2	3	4
Peg Tubes	N/A	1	2	3	4
Restraints	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
4 pt	N/A	1	2	3	4
Shoulder strap	N/A	1	2	3	4
Hand Mitts	N/A	1	2	3	4
Wrist	N/A	1	2	3	4
Ankle	N/A	1	2	3	4
Pelvic Strap	N/A	1	2	3	4
Other	Not Applicable	Inexperienced	Limited Experience	Experienced	Highly Experienced
Ability to evaluate and assign Functional Independence Score	N/A	1	2	3	4
AIDS Patients	N/A	1	2	3	4
Burn Management	N/A	1	2	3	4
Cardiac Rehabilitation	N/A	1	2	3	4
Function Capacity Evaluation	N/A	1	2	3	4
Geriatrics	N/A	1	2	3	4
Manual therapy	N/A	1	2	3	4
Massage Therapy	N/A	1	2	3	4
Muscle Stimulation	N/A	1	2	3	4
Pain Management/giving meds	N/A	1	2	3	4
Physical Capacity	N/A	1	2	3	4
Pulmonary Rehab	N/A	1	2	3	4
Sterilization Technique	N/A	1	2	3	4
TENS	N/A	1	2	3	4
Wound Debridement/Dressing Change	N/A	1	2	3	4