Occupational Therapist Assistant

COTA

Occupational Therapist Assistant Checklist

Name
Date
Date Format: MM slash DD slash YYYY
Phone
Email
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 Independently
Work Settings
1 2 3 4
Acute Care Hospital
Rehab Hospital/Sub-Acute
Extended Care Facility
Assisted Living
Skilled Nursing Facility
1 2 3 4
Hospital Outpatient
Outpatient Clinic
Home Healthcare
School Setting
Pediatrics
Orthopedic
1 2 3 4
Hand Injury
Total Hip/Knee Replacement
Arthritis-Energy Conservation
1 2 3 4
Hip Fracture
Upper Extremity Joint Replace
Arthritis-Joint Protection
ADL Training
1 2 3 4
Adaptive Equipment
Wheelchair Eval & Positioning
1 2 3 4
Home Assessment
Driver's Evaluation/Education
Strength Training
Nautilius/Eagle
Modalities/Manual Skills/Therapies
1 2 3 4
Feeding Technique Oral/Motor
Kinesiotaping
Luidotherapy
Diathermy
Electrical Stimulation
Iontopheresis
Burn/Wound Management
Vision Rehabilitation
1 2 3 4
Edema Massage
Aquatic Therapy
Paraffin Bath
Myofascial Release
Biofeedback
TENS
Cardiac Rehabilitation
Neurologic
1 2 3 4
Brain Injury
CVA
Progressive Neuro Disorder
1 2 3 4
SCI
Peripheral Nerve Injury
Feeding/Swallowing
Prosthetics/Orthotics
1 2 3 4
Above/Below Knee Prosthetics
Static Splints
1 2 3 4
Upper Extremity Prosthe
Dynamic Splints
Vocational Training
1 2 3 4
Functional Capacity Evaluation
Cognitive Assessment
Work Hardening
1 2 3 4
Perceptual Assessment
Job Task Analysis
Pediatrics
1 2 3 4
Development Testing
Visual Perceptual Skills Testing
Feeding/Swallowing
Sensory Diet Program
1 2 3 4
Sensory Integrative Testing
ADLs
Orthotics
Handwriting
Billing/Documentation
1 2 3 4
RUG Levels
Medicare Part B
1 2 3 4
Medicare Part A
Medicaid/Medical
Professional Knowledge and Skills
1 2 3 4
Management Experience
National Patient Safety Goals
Population-Based Care
Pain Assessment & Management
1 2 3 4
Screening/Adding Caseload
Fall Risk Assess/Prevention
Infection 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.
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Comments
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	1	2	3	4
Acute Care Hospital
Rehab Hospital/Sub-Acute
Extended Care Facility
Assisted Living
Skilled Nursing Facility

	1	2	3	4
Hospital Outpatient
Outpatient Clinic
Home Healthcare
School Setting
Pediatrics

	1	2	3	4
Hand Injury
Total Hip/Knee Replacement
Arthritis-Energy Conservation

	1	2	3	4
Hip Fracture
Upper Extremity Joint Replace
Arthritis-Joint Protection

	1	2	3	4
Home Assessment
Driver's Evaluation/Education
Strength Training
Nautilius/Eagle

	1	2	3	4
Feeding Technique Oral/Motor
Kinesiotaping
Luidotherapy
Diathermy
Electrical Stimulation
Iontopheresis
Burn/Wound Management
Vision Rehabilitation

	1	2	3	4
Edema Massage
Aquatic Therapy
Paraffin Bath
Myofascial Release
Biofeedback
TENS
Cardiac Rehabilitation

	1	2	3	4
Functional Capacity Evaluation
Cognitive Assessment
Work Hardening

	1	2	3	4
Development Testing
Visual Perceptual Skills Testing
Feeding/Swallowing
Sensory Diet Program

	1	2	3	4
Management Experience
National Patient Safety Goals
Population-Based Care
Pain Assessment & Management

	1	2	3	4
Adaptive Equipment
Wheelchair Eval & Positioning

	1	2	3	4
Brain Injury
CVA
Progressive Neuro Disorder

	1	2	3	4
SCI
Peripheral Nerve Injury
Feeding/Swallowing

	1	2	3	4
Above/Below Knee Prosthetics
Static Splints

	1	2	3	4
Screening/Adding Caseload
Fall Risk Assess/Prevention
Infection Prevention