Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
ACUTE
Gait training 0 1 2
General medical 0 1 2
General surgical 0 1 2
Orthopedics 0 1 2
Wound care 0 1 2
Cardiac 0 1 2
ICU/SICU 0 1 2
Oncology 0 1 2
Geriatrics 0 1 2
Respiratory 0 1 2
Transplants 0 1 2
NEUROLOGICAL
CVA 0 1 2
SCI 0 1 2
MS 0 1 2
Parkinson’s 0 1 2
TBI 0 1 2
WORK HARDENING
FCE 0 1 2
Work site evaluation 0 1 2
Work hardening 0 1 2
Chronic Pain 0 1 2
NDT 0 1 2
Aquatics 0 1 2
Home care
Oasis paperwork 0 1 2
EXTENDED CARE
Free standing 0 1 2
Hospital based 0 1 2
MDS 0 1 2
RUGS Levels 0 1 2
PEDIATRICS
Acute 0 1 2
Rehabiltation 0 1 2
School based 0 1 2
Positioning aids 0 1 2
Wheelchair fitting 0 1 2
Neonatal 0 1 2
Outpatient 0 1 2
Oral monitor 0 1 2
Assisted tech/classroom adaptation 0 1 2
REHABILITATION - Neurological
SCI 0 1 2
CVA 0 1 2
TBI 0 1 2
General medicine/deconditioning 0 1 2
Guillane Barre 0 1 2
MS 0 1 2
MD 0 1 2
Ortho 0 1 2
Cardiac/Pulmonary 0 1 2
Amputee 0 1 2
Home evaluations 0 1 2
OUTPATIENT - Manual Therapy
Spinal 0 1 2
Extremity 0 1 2
Backs
McKenzie 0 1 2
Maitland 0 1 2
Other 0 1 2
Necks
McKenzie 0 1 2
Maitland 0 1 2
Other 0 1 2
Knees
ACL rehab 0 1 2
Arthroscopic surgery 0 1 2
Patello-Femoral Disorders 0 1 2
Soft tissue trauma 0 1 2
Wound care 0 1 2
Arthritis 0 1 2
Progressive strengthening 0 1 2
Orthotics prescription 0 1 2
Prosthetics prescription 0 1 2
Sports Medicine 0 1 2
Modalities
US/phono 0 1 2
Traction 0 1 2
Heat/Cold 0 1 2
Myofascial release 0 1 2
Electrical stimulation 0 1 2
Whirlpool 0 1 2
Iontophoresis 0 1 2
EMG/NCV 0 1 2
Biofeedback 0 1 2
TENS 0 1 2
ISOKINETICS
BTE 0 1 2
Cybex Biodex 0 1 2
KinCom 0 1 2
Lido 0 1 2
DOCUMENTATION
700 & 701 Forms 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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