Orthopedic Tech

One program to handle all talent management needs from acquisition to development

Personal Information

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Overall Score

Name(Required)

First Middle Last

Last 4 Digits of Social Security Number

Email(Required)

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Date

MM slash DD slash YYYY

Proficiency Scale

1 – No Experience
2 – Need Training
3 – Able to perform with supervision
4 – Able to perform independently

Skills-Casts-Fiberglass/ Synthetic

Long arm in neutral position(Required)

Long arm in flexion with ulnar deviation w/ 3 point molding(Required)

Long arm pronation or supination(Required)

Short arm in neutral position(Required)

Short arm in flexion with ulnar deviation with 3 point molding(Required)

Short leg walking in neutral position(Required)

Short leg walking in equines(Required)

Short leg non weight bearing in equines(Required)

Short leg non weight bearing in neutral position(Required)

P.T.B. with correct molding(Required)

Long leg walker(Required)

Cylinder cast(Required)

Long leg non weight bearing in neutral position with correct knee flexion(Required)

Long leg non weight bearing with molding for widened mortise(Required)

Toe plates applied to short and long leg casts(Required)

Gauntlet with outrigger-hand(Required)

Gauntlet with outrigger and molding-hand(Required)

Long arm navicular thumb spica(Required)

Long arm thumb spica(Required)

Cast saw

Remove casts(Required)

Trim(Required)

Wedging(Required)

Remove and replace cast blades(Required)

Window casts(Required)

Univalve casts(Required)

Skills-Splints

Short leg posterior(Required)

Short leg sugar tong(Required)

Thumb spica(Required)

Hand muff splint(Required)

Foot muff splint(Required)

Gutter splint lateral and medial(Required)

Short arm volar(Required)

Long arm posterior with side walls(Required)

Sugar tong double long arm(Required)

Sugar tong short arm(Required)

Braces, Immobilizers

Wrist brace(Required)

Ace bandage(Required)

Shoulder immobilizer(Required)

Slings(Required)

Hinged knee brace(Required)

Velcro knee brace(Required)

Cervical collar

Soft(Required)

Hard(Required)

Traction

Bucks(Required)

Bryant’s(Required)

Traction cont.

Overhead bed frame(Required)

Splint Russells(Required)

Balanced suspension(Required)

Assist MD with fracture reduction(Required)

Cervical(Required)

Physical Therapy

Range of motion exercises(Required)

Gait training(Required)

Crutches and canes

Fitting(Required)

Instruction on patient use(Required)

Miscellaneous

Removal of sutures(Required)

Making various casts and molds(Required)

Preparing plaster of Paris mix(Required)

Make alterations to casts to alleviate pressure points(Required)

Assisting with research projects(Required)

Assist with skin grafts(Required)

Assist with stump revisions(Required)

Assist with pin insertions(Required)

Assist with debridements(Required)

Application of Minerva/ Halo jacket(Required)

Sterile dressing techniques(Required)

Removal of orthopedic devices (list):(Required)

Age Specific Competencies

Infant (Birth - 1 year)(Required)

Preschooler (ages 2-5 years)(Required)

Childhood (ages 6-12 years)(Required)

Adolescents (ages 13-21 years)(Required)

Young Adults (ages 22-39 years)(Required)

Older Adults (ages 65-79 years)(Required)

Elderly (ages 80+ years)(Required)

Authorizations

Legal 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. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

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