GENERAL INFORMATION

Note: * Denotes a required field.

Please enter your full name as it appears on your Social Security Card: First Name   Middle Name   Last Name  * Please enter the Last Four digits of your Social Security Number:  -   -   *       Please check here if you do not hold a valid social security card. Please provide your contact information: Phone Number  * E-mail Address  * Confirm E-mail Address  * Type your e-mail address again above.

This profile is for use by healthcare professionals in the COTA discipline and specialty. It will not be a determining factor for the program.

CHECKLIST INSTRUCTIONS

Please mark your level of experience      1. No theory and/or experience      2. Limited experience/need supervision and/or support      3. Experienced/minimal support needed to perform      4. Proficient/can perform independently

Orthopedics

1

2

3

4

Total Hip Replacements

Total Knee Replacements

UE Joint Replacements

Amputation

Fractures/Dislocations

Trauma Hand Injury

Arthritis

Back Injury

Multi-trauma

General Acute Care

1

2

3

4

!Discharge Planning

Home Assessment

Home Modification/Adaptation

Driver Re-education

!Neurological

Traumatic Brain Injury

CVA/Stroke

Spinal Cord Injury

Coma Management

Peripheral Nerve Injury

Reflex Sympathetic Dystrophy

Parkinson's

Multiple Sclerosis

Alzheimer's

Cumulative Trauma Disorders

Gullian Barre Syndrome

ALS

Laminectomy

Crainiotomy

!Pediatrics

NICU

Congenital Anomalies

Cerebral Palsy

Spina Bifida

Musculoskeletal Disorders

Juvenile Rheumatoid Arthritis

Arthrogryposis

Genetic Conditions

Learning Disabilities

Peravise Developmental Disorders

AIDS

General Medical Conditions

Sensory Integration

!Orthotics/Prosthetics

Static Splinting

Dynamic Splinting

Serial Inhibitory Casting

UE Prosthetics Assess/Train

LE Prosthetics Assess/Train

Hand Therapy

Y/N Modality Certification

Yes

No

Y/N Certified Hand Therapist

Yes

No

Techniques

1

2

3

4

!Assessments

Independent Living Skills/Life Management Skills

Physical

Psychosocial

ADL

Cognitive/Perceptual

Sensory

Therapeutic Adaptation

Positioning

Restraint Reduction

Home Safety

Modalities

!Treatment

Neurodevelopmental

Transfer Training

ADL Retraining

Home Management

Post-op Client

Education/Precautions

Positioning

Tone Management

Postural Re-education

Multi Trauma

Work Simplification/Energy Conservation

Sensory Re-education

Sensory Integration

Manual Therapy

Functional Mobility/Retraining

Prosthetic Training

Valpar

BTE

Assistive Technology

Psychosocial Integration

Reflex Management

Documentation

1

2

3

4

Mental Health

Medicare Documentation

700 & 701 Forms

PPS

MDS Form

Primary Experience

1

2

3

4

General Acute Care

Rehabilitation

Skilled Nursing Facility

Home Health Care

Outpatient Services

Industrial Medical Clinic

Hand Clinic

CHT-Certified Hand Therapist

Children's Hospital

School Systems

Psychiatric Hospital

Please read and agree to the statements below by marking the checkbox. You will not be able to submit until you have marked the checkbox. * I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize Hudson Staffing to release this COTA Skills Checklist to the client facilities in relation to consideration of employment as a healthcare professional with those facilities.

Privacy Note: Hudson Staffing will record anonymous electronic information about your connection when you click on the submit button. This information is used for security purposes only. This information will include your IP Address (35.173.48.53) which will be used as a digital signature.