*required fields Occupational 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) *      Date*                                                             Phone*                 Recruiter   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

Area	Not Applicable	Inexperienced	Limited	Experienced	Highly Experienced
Experience Level
CVA Rehabilitation	N/A	1	2	3	4
Coma Management	N/A	1	2	3	4
Hand Injury	N/A	1	2	3	4
Nerve Injury	N/A	1	2	3	4
Tendon Repair	N/A	1	2	3	4
Reattachment	N/A	1	2	3	4
Head Trauma	N/A	1	2	3	4
Spinal Cord Injury	N/A	1	2	3	4
Amputee	N/A	1	2	3	4
Upper Extremity	N/A	1	2	3	4
Lower Extremity	N/A	1	2	3	4
Pediatrics	N/A	1	2	3	4
Neurodevelopment Testing	N/A	1	2	3	4
Disability Sequence Test	N/A	1	2	3	4
Orhtotics	N/A	1	2	3	4
Equipment Assessment Device	N/A	1	2	3	4
Early Intervention	N/A	1	2	3	4
NICU Treatment	N/A	1	2	3	4
Neurodevelopment Treatment	N/A	1	2	3	4
Sensory Integrative Treatment	N/A	1	2	3	4
Developmental Delay	N/A	1	2	3	4
Mental Retardation	N/A	1	2	3	4
Cerebral Palsy	N/A	1	2	3	4
Learning Disability	N/A	1	2	3	4
Spina Bifida	N/A	1	2	3	4
Discharge Planning	N/A	1	2	3	4
Activities of Daily Living	N/A	1	2	3	4
Prosthetics / Orthotics	N/A	1	2	3	4
Above Knee Prosthetics	N/A	1	2	3	4
Below Knee Prosthetics	N/A	1	2	3	4
Upper Extremity Prothetics	N/A	1	2	3	4
Orthoplast	N/A	1	2	3	4
Static Splints	N/A	1	2	3	4
Serial / Inhibitory	N/A	1	2	3	4
Adaptive Equipment	N/A	1	2	3	4
Assessment	N/A	1	2	3	4
Fabrication	N/A	1	2	3	4
Wheelchair (seating & ordering)	N/A	1	2	3	4
Functional Activities	N/A	1	2	3	4
Home Environment	N/A	1	2	3	4
Activities of Daily Living	N/A	1	2	3	4
Pre-Discharge Planning	N/A	1	2	3	4
Adaptive Equipment	N/A	1	2	3	4
Standardized Assesments	N/A