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My responses in this checklist represent a true reflection of my experience and comfort level.

Please self-rate your comfort level in performing tasks in connection with the below checklist. Rate your level of comfort for each line item by following the below ranking system. Simply fill in the appropriate option immediately following the rating number.		  
 
 
   
 
 Signature                 :
     
 
  Date                  :
     
          Phone                  :
   
    My Recruiting Professional at Health Source Group is:
   *

          Level of Comfort/Experience

          N/A=Non-applicable

          1=Inexperienced in this area

          2=Limited comfort/experience in this area

          3=Comfortable/experienced in this area

          4= comfortable/highly experienced in this area



       Certifications: (Check all that apply)

        BLS/BCLS/CPR:  
        CRRN:  
 

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Work Settings

 

 

 

 

 

General Acute Care

N/A  

1

2

3

4

Home Health

N/A  

1

2

3

4

Nursing Home

N/A  

1

2

3

4

Outpatient Clinic

N/A  

1

2

3

4

Pediatric Rehab

N/A  

1

2

3

4

Acute Rehab Hospital

N/A  

1

2

3

4

Rehab Unit in Hospital

N/A  

1

2

3

4

 

Neuro

 

 

 

 

 

Cerebral Vascular Accident

N/A  

1

2

3

4

Coma Patients

N/A  

1

2

3

4

Head Trauma

N/A  

1

2

3

4

Spinal Cord Injury

N/A  

1

2

3

4

Parkinson’s Disease

N/A  

1

2

3

4

Traumatic Brain Injury

N/A  

1

2

3

4

Neuromuscular disease

N/A  

1

2

3

4

Post Craniotomy

N/A  

1

2

3

4

Bowel/Bladder programs

N/A  

1

2

3

4

 

Ortho

 

 

 

 

 

Arthritis Programs

N/A  

1

2

3

4

Back Syndrome

N/A  

1

2

3

4

Cervical Traction

N/A  

1

2

3

4

Continuous Passive Motion Machine N/A

N/A  

1

2

3

4

Gait Training

N/A  

1

2

3

4

Hand Injury

N/A  

1

2

3

4

Hip Fractures

N/A  

1

2

3

4

Care of Patient with Halo

N/A  

1

2

3

4

Hot/Cold Packs

N/A  

1

2

3

4

Mobilization Techniques

N/A  

1

2

3

4

Neck Injuries

N/A  

1

2

3

4

TMJ Dysfunction

N/A  

1

2

3

4

Total Hip Replacement

N/A  

1

2

3

4

Total Knee Replacement

N/A  

1

2

3

4

 

Pulmonary

 

 

 

 

 

Assessment of breath sounds

N/A  

1

2

3

4

Chest Physiotherapy

N/A  

1

2

3

4

Oximetry

N/A  

1

2

3

4

Nasal cannula

N/A  

1

2

3

4

Face Mask

N/A  

1

2

3

4

Portable O2 tank

N/A  

1

2

3

4

Nasotracheal Suctioning

N/A  

1

2

3

4

Tracheal Suctioning

N/A  

1

2

3

4

Care of patient w/Mechanical Vent

N/A  

1

2

3

4

COPD

N/A  

1

2

3

4

 

Pediatrics

 

 

 

 

 

Cerebral Palsy

N/A  

1

2

3

4

Activities of Daily Living

N/A  

1

2

3

4

Learning Disabilities

N/A  

1

2

3

4

Orthotics

N/A  

1

2

3

4

Spina Bifida

N/A  

1

2

3

4

Autism

N/A  

1

2

3

4

AK Prosthetics

N/A  

1

2

3

4

Amputees

N/A  

1

2

3

4

BK Prosthetics

N/A  

1

2

3

4

Bracing/ Joint Immobilization

N/A  

1

2

3

4

Resting Splints

N/A  

1

2

3

4

Casts/check for circulation

N/A  

1

2

3

4

Upper Extremity Prosthetics

N/A  

1

2

3

4

 

Nutritional Requirements

 

 

 

 

 

Thickened Liquids

N/A  

1

2

3

4

Minimal

N/A  

1

2

3

4

Thick

N/A  

1

2

3

4

Extra Thick

N/A  

1

2

3

4

Pudding Thick

N/A  

1

2

3

4

NG Tubes

N/A  

1

2

3

4

Peg Tubes

N/A  

1

2

3

4

 

Restraints

 

 

 

 

 

4 pt

N/A  

1

2

3

4

Shoulder strap

N/A  

1

2

3

4

Hand Mitts

N/A  

1

2

3

4

Wrist

N/A  

1

2

3

4

Ankle

N/A  

1

2

3

4

Pelvic Strap

N/A  

1

2

3

4

 

Other

 

 

 

 

 

Ability to evaluate and assign Functional Independence Score

N/A  

1

2

3

4

AIDS Patients

N/A  

1

2

3

4

Burn Management

N/A  

1

2

3

4

Cardiac Rehabilitation

N/A  

1

2

3

4

Function Capacity Evaluation

N/A  

1

2

3

4

Geriatrics

N/A  

1

2

3

4

Manual therapy

N/A  

1

2

3

4

Massage Therapy

N/A  

1

2

3

4

Muscle Stimulation

N/A  

1

2

3

4

Pain Management/giving meds

N/A  

1

2

3

4

Physical Capacity

N/A  

1

2

3

4

Pulmonary Rehab

N/A  

1

2

3

4

Sterilization Technique

N/A  

1

2

3

4

TENS

N/A  

1

2

3

4

Wound Debridement/Dressing Change N/A

N/A  

1

2

3

4