Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
ORTHOPEDICS
Total hip replacements 0 1 2
Total knee replacements 0 1 2
UE joint replacements 0 1 2
Amputation 0 1 2
Fractures/dislocations 0 1 2
Traumatic hand injury 0 1 2
Arthritis 0 1 2
Back Injury 0 1 2
Multi-trauma 0 1 2
GENERAL ACUTE CARE - Discharge Planning
Home assessment 0 1 2
Home modification/adaptation 0 1 2
Driver re-education 0 1 2
NEUROLOGICAL
Traumatic brain injury 0 1 2
CVA/stroke 0 1 2
Spinal cord injury 0 1 2
Coma management 0 1 2
Peripheral nerve injury 0 1 2
Reflex sympathetic dystrophy 0 1 2
Parkinson’s 0 1 2
Multiple sclerosis 0 1 2
Alzheimer’s 0 1 2
Cumulative trauma disorders 0 1 2
Guillian Barre Syndrome 0 1 2
ALS 0 1 2
Laminectomy 0 1 2
Craniotomy 0 1 2
PEDIATRICS
NICU 0 1 2
Congenital anomalies 0 1 2
Cerebral palsy 0 1 2
Spina bifida 0 1 2
Musculoskeletal disorders 0 1 2
Genetic conditions 0 1 2
Learning disabilities 0 1 2
Development disorders 0 1 2
AIDS 0 1 2
General medical conditions 0 1 2
Sensory integration 0 1 2
ORTHOTICS/PROSTHETICS
Static splinting 0 1 2
Dynamic splinting 0 1 2
Serial inhibitory casting 0 1 2
UE prosthetics assess/train 0 1 2
LE prosthetics assess/train 0 1 2
HAND THERAPY
Modality Certification No Yes
Certified Hand Therapist No Yes
TECHNIQUES - Assessments
Independent living skills/
life management skills 0 1 2
Physical 0 1 2
Psychosocial 0 1 2
ADL 0 1 2
Cognitive/perceptual 0 1 2
Sensory 0 1 2
Therapeutic adaptation 0 1 2
Positioning 0 1 2
Restraint reduction 0 1 2
Home safety 0 1 2
Modalities 0 1 2
TREATMENT
Neurodevelopmental 0 1 2
Transfer training 0 1 2
ADL retraining 0 1 2
Home management 0 1 2
Post-op client education/precautions 0 1 2
Positioning 0 1 2
Juvenile rheumatoid arthritis 0 1 2
Arthrogryposis 0 1 2
Multi-trauma 0 1 2
Work simplification/energy conservation 0 1 2
Sensory re-education 0 1 2
Sensory integration 0 1 2
Manual therapy 0 1 2
Functional mobility retraining 0 1 2
Prosthetic training 0 1 2
Valpar 0 1 2
BTE 0 1 2
Assistive technology 0 1 2
Psychosocial integration 0 1 2
Tone management 0 1 2
Postural re-education 0 1 2
Reflex management 0 1 2
TREATMENT (CONT)
Mental Health 0 1 2
Medicare documentation 700 & 701 0 1 2
Forms 0 1 2
PPS 0 1 2
MDS Form 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(Birth - 1 Year) B= Pediatric/Adolescent(1-18 Yrs) C=Adultt(19-64 Yrs) D=Geriatric(65 + Yrs)
A
B
C
D
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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