* Please note that fields marked with a * are required.
Date
* Applicant's Name: Last
* First
Middle Initial
* NBCOT ID #
* Exam Date
Profession OT COTA
Please Mark Your Level of Experience 1 - No Experience 2 - Limited Experience (Assistance Needed) 3 - Some Experience (Needs Resource for Backup) 4 - Very Experienced (Requires No Supervision)
Work Settings
1
2
3
4
General Acute Care
Home Health
Outpatient Clinic
Pediatric Rehab
Psychiatric Hospital
Acute Rehab Hospital
Rehab Unit in Hospital
School System
Skilled Nursing Facility
Industrial Medicine
Orthopedics
Arthritis Program
General Ortho (Knee, Shoulder, Ankle)
Hand Injury
Hip Fractures
Mobilization Techniques
Total Hip / Total Knee
Total Joint Replacement (Upper Extremities)
Neuro
Cerebral Vascular Accident (CVA)
Cognitive Retraining
Head Trauma
Spinal Cord Injury
Parkinson's Disease
Traumatic Brain Injury
Pediatrics
Cerebral Palsy
Developmental Screening
Early Intervention
Learning Disabilities
Neurodevelopment Testing
Sensory Integrative Testing
Spina Bifida
Visual Perception Testing
Autism
Down's Syndrome
Mental Retardation
Modalities
Biofeedback
Edema Massage
Feeding Techniques
Fluidotherapy
Oral Motor Facilitation
Muscle Stimulation
Paraffin Bath
TENS
Therapeutic Massage
Therapeutic Pool
Prosthetics/Orthotics
Dynamic Splints
Functional Splinting
Orthotics
LE Prosthetics
Serial / Inhibitory Casting
Static Splints
UE Prosthetics
Other
Activities of Daily Living (ADL)
Adaptive Equipment
Amputees
Burn Management
Driving Evaluation
Dysphagia
Energy Conservation
Family Education
Gait Analysis
Geriatrics
Group Dynamics
Home Accessibility
Job Task Analysis
Oncology
Pain Management
Perceptual Motor Testing
Pulmonary Rehab
Range of Motion
Sensation Testing
Wheelchair Evaluation
Wheelchair Ordering
Wheelchair Position Testing
Work Capacity Evaulation
Work Hardening (BTB)
Work Hardening (Valpar)
Other Skills / Credentials Please list any aditional experience or skills that have not been included above:
* Signature (Please Type Full Name)
* Date
