* = Required Information
This profile is for use by Physical Therapists with more than one year of experience in their discipline and specialty. It will not be a determining factor for the program. Return this checklist to us by mail or fax it toll free to 260-442-8884.
Please mark your level of experience
A - Theory, no practice
B - Intermittent experience
C - One - two years experience
D - Two plus years experience
A. Orthopedic
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
B. Neurologic
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
C. Sports Medicine
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
D.Modalities/Manual Skills
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
10. Hot/cold packs
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
22. Traction
A B C D
A B C D
A B C D
A B C D
A B C D
E. Prosthetics/Orthotics
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
F. Pediatrics
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
G. Computerized Testing
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
H.Other
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
A B C D
Please check the boxes below for each age group for which you have expertise in providing age-appropriate nursing care.
AGE SPECIFIC PRACTICE CRITERIA
A. Newborn/Neonate (birth - 30 days)
B. Infant (30 days - 1 year)
C. Toddler (1 - 3 years)
D. Preschooler (3 - 5 years)
E. School age children (5 - 12 years)
F. Adolescents (12 - 18 years)
G. Young adults (18 - 39 years)
H. Middle adults (39 - 64 years)
I. Older adults (64+)
EXPERIENCE WITH AGE GROUPS:
A B C D E F G H I
A B C D E F G H I
A B C D E F G H I
BCLS

CPR

Other


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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 the Company to release this Physical Therapy Skills Checklist to their Client facilities in relation to consideration of employment as a Traveler with those facilities.

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