Physical Therapy/PTA Skills Checklist One program to handle all talent management needs from acquisition to development Personal Information This field is hidden when viewing the formOverall ScoreName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) This field is hidden when viewing the formDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyClinical SettingsOutpatient Clinic(Required) 1 2 3 4 Rehab Hospital(Required) 1 2 3 4 Skilled Nursing Facility(Required) 1 2 3 4 Sports Medicine Clinic(Required) 1 2 3 4 Children's Hospital(Required) 1 2 3 4 General Acute Care Facility(Required) 1 2 3 4 School Setting(Required) 1 2 3 4 Home Health(Required) 1 2 3 4 Pediatric Clinic(Required) 1 2 3 4 Computerized ChartingHand Held Devices(Required) 1 2 3 4 Word(Required) 1 2 3 4 Excel(Required) 1 2 3 4 Cerner(Required) 1 2 3 4 EPIC(Required) 1 2 3 4 McKesson(Required) 1 2 3 4 Meditech(Required) 1 2 3 4 Knowledge of Payment SourcesMedicare(Required) 1 2 3 4 Medicaid(Required) 1 2 3 4 MDS(Required) 1 2 3 4 RUG Levels(Required) 1 2 3 4 Modalities/SkillsMuscle Stimulation(Required) 1 2 3 4 Paraffin Bath(Required) 1 2 3 4 Acuscope(Required) 1 2 3 4 Biofeedback(Required) 1 2 3 4 Continuous Passive Machine(Required) 1 2 3 4 Craniosacral Therapy(Required) 1 2 3 4 Electro-acupuncture(Required) 1 2 3 4 Extremity Mobilization(Required) 1 2 3 4 Fluidotherapy(Required) 1 2 3 4 Hot/Cold Packs(Required) 1 2 3 4 Hubbard Tank(Required) 1 2 3 4 Therapeutic Pool(Required) 1 2 3 4 Whirlpool(Required) 1 2 3 4 Massage(Required) 1 2 3 4 Muscle Energy Techniques(Required) 1 2 3 4 Neuro Probe(Required) 1 2 3 4 Strain/Counterstrain Techniques(Required) 1 2 3 4 Spinal Mobilization(Required) 1 2 3 4 TENS(Required) 1 2 3 4 Cervical Traction(Required) 1 2 3 4 Lumbar Traction(Required) 1 2 3 4 Ultrasound(Required) 1 2 3 4 Wound Dressing(Required) 1 2 3 4 NeurologicHead Trauma(Required) 1 2 3 4 Stroke Rehabilitation(Required) 1 2 3 4 Neurosurgery(Required) 1 2 3 4 Spinal Cord Injuries(Required) 1 2 3 4 Adaptive Equipment(Required) 1 2 3 4 Functional Splinting(Required) 1 2 3 4 OrthopedicArthritis Programs(Required) 1 2 3 4 Hip Fractures(Required) 1 2 3 4 Backs(Required) 1 2 3 4 Hand Injuries(Required) 1 2 3 4 Mobilization Techniques(Required) 1 2 3 4 Total Joint Replacement(Required) 1 2 3 4 Total Hip / Knee Replacement(Required) 1 2 3 4 Transmandibular Joint Dysfunction(Required) 1 2 3 4 Neck Injuries(Required) 1 2 3 4 SportsBracing/Joint Immobilization(Required) 1 2 3 4 Biodex(Required) 1 2 3 4 Cybex(Required) 1 2 3 4 LIDO(Required) 1 2 3 4 Orthotron(Required) 1 2 3 4 Nautilus/Eagle(Required) 1 2 3 4 Strength and Endurance Training(Required) 1 2 3 4 Prosthetics/OrthoticsAbove Knee Prosthetics(Required) 1 2 3 4 Below Knee Prosthetics(Required) 1 2 3 4 Upper Extremity Prosthetics(Required) 1 2 3 4 Ankle Foot Orthosis(Required) 1 2 3 4 PediatricsOrthotics(Required) 1 2 3 4 Early Intervention(Required) 1 2 3 4 Equipment Assessment(Required) 1 2 3 4 Neurodevelopmental Treatment(Required) 1 2 3 4 Additional ResponsibilitiesBurn Management(Required) 1 2 3 4 Cardiac Rehabilitation(Required) 1 2 3 4 Inservice Education(Required) 1 2 3 4 Wheelchair/Equipment Assessment(Required) 1 2 3 4 Age SpecificNewborn/Neonatal (up to 30 days)(Required) 1 2 3 4 Infant (30 days to 1 year)(Required) 1 2 3 4 Toddler (1 to 3 years)(Required) 1 2 3 4 Preschooler (3 to 5 years)(Required) 1 2 3 4 School Age (5 to 12 years)(Required) 1 2 3 4 Adolescents (12 to 18 years)(Required) 1 2 3 4 Young Adults (18 to 39 years)(Required) 1 2 3 4 Middle Adults (40 to 64 years)(Required) 1 2 3 4 Older Adults (65 & up)(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. 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