Full Name :
Phone :
Email :

1 = No Experience		3 = Experienced
2 = Intermittent Experience		4 = Supervise and Teach

Adult	1	2	3	4
CVA Rehabilitation
Coma Management
Hand Injury
Hand Nerve Injury
Hand Tendon Repair
Hand Reattachment
Head trauma
Spinal cord injury
Amputee
Upper Extremity
Lower Extremity
Pediatrics	1	2	3	4
Neurodevelopment testing
Disability sequence test
Orthotics
Equip assessment adaptive
Early Intervention
NICU Treatment
Neurodevelopmental Treatment
Sensory Integrative Treatment
Developmental Delay
Mental Retardation
Cerbral Palsy
Learning Disability
Spina Bifida
Discharge Planning
Activities of daily living
Prosthetics/Orthotics	1	2	3	4
Above knee prosthetics
Below knee prosthetics
Upper extremity prosthetics
Orthoplast
Static splints
Serial Inhibitory
Adaptive Equipment	1	2	3	4
Equip Assessment
Equip Fabrication
Wheelchair
Functional Activities
Home Environment
Equip Activities of Daily Living
Equip PreDischarge Planning
Standardized Assessments
Group Treatment
Substance Abuse
Crisis Intervention
Acute Disorder
Chronic Disorder
Community Reentry
Prevocational Training	1	2	3	4
Perceptual Assessment
Cognitive Assessment
Work Hardening
Myofascial Release Techniques
Joint Mobilization
Biofeedback
TENS
Fluidotherapy
Other	1	2	3	4
Work capacity evaluation
Functional capacity evaluation
Cardiac rehabilitation
Chest physiotherapy
Burn Management
Geriatrics
Developmental Disability
Home Accessibility
Driving Evaluation
Cognitive Retraining
Group Dynamics
In-service Education
Computer Familiarity
Feeding Techniques
Family Education
Patient Education
Energy Conservation
Sensory Evaluation
CPM
AIDS
Arthritis
Feldenkrais
OBRA Nursing Home Restoration
Research
Senior Therapist
Student Supervisor

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