Occupational Therapist Assistant Checklist Name Date MM slash DD slash YYYY State LicenseState LicenseAlabamaAkaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPenssylvaniaRhode IslandSouth CarlinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPhoneEmail Please list all the documentation systems you are proficient in:LEVELS OF EXPERIENCE: Use the following values to rate your level of experience and/or frequency within the last two years. 1=No Experience 2=Limited Experience/Supervision or Support 3=Experience/Needs Minimal Support 4=Proficient IndependentlyWork Settings 1234Acute Care HospitalRehab Hospital/Sub-AcuteExtended Care FacilityAssisted LivingSkilled Nursing Facility1234Hospital OutpatientOutpatient ClinicHome HealthcareSchool SettingPediatricsOrthopedic 1234Hand InjuryTotal Hip/Knee ReplacementArthritis-Energy Conservation1234Hip FractureUpper Extremity Joint ReplaceArthritis-Joint ProtectionADL Training 1234Adaptive EquipmentWheelchair Eval & Positioning1234Home AssessmentDriver's Evaluation/EducationStrength TrainingNautilius/EagleModalities/Manual Skills/Therapies 1234Feeding Technique Oral/MotorKinesiotapingLuidotherapyDiathermyElectrical StimulationIontopheresisBurn/Wound ManagementVision Rehabilitation1234Edema MassageAquatic TherapyParaffin BathMyofascial ReleaseBiofeedbackTENSCardiac RehabilitationNeurologic 1234Brain InjuryCVAProgressive Neuro Disorder1234SCIPeripheral Nerve InjuryFeeding/SwallowingProsthetics/Orthotics 1234Above/Below Knee ProstheticsStatic Splints1234Upper Extremity ProstheDynamic SplintsVocational Training 1234Functional Capacity EvaluationCognitive AssessmentWork Hardening1234Perceptual AssessmentJob Task AnalysisPediatrics 1234Development TestingVisual Perceptual Skills TestingFeeding/SwallowingSensory Diet Program1234Sensory Integrative TestingADLsOrthoticsHandwritingBilling/Documentation 1234RUG LevelsMedicare Part B1234Medicare Part AMedicaid/MedicalProfessional Knowledge and Skills 1234Management ExperienceNational Patient Safety GoalsPopulation-Based CarePain Assessment & Management1234Screening/Adding CaseloadFall Risk Assess/PreventionInfection Prevention By checking this box, I attest that the information given is true and accurate to the best of my knowledge and that I am the individual completing this form. I verify that the representation of my skills associated proficiency levels in this document are a true and accurate reflection of my abilities based on my work experience. CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
