OMNI Home Care - PT Checklist

PT Checklist

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.

Typed Name* (Typing your name below serves as an electronic signature)	Date*
Phone*	Recuiter*

   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=Very comfortable/highly experienced in this area

Area

Not Applicable

Inexperienced

Limited

Experienced

Highly Experienced

Start of Care/Oasis

N/A

1

2

3

4

Home Care experience

N/A

1

2

3

4

Orthopedic

N/A

1

2

3

4

Neurologic

N/A

1

2

3

4

Vestibular

N/A

1

2

3

4

Geriatrics

N/A

1

2

3

4

Lymphedema

N/A

1

2

3

4

Anodyne

N/A

1

2

3

4

Area	Not Applicable	Inexperienced	Limited	Experienced	Highly Experienced

Start of Care/Oasis	N/A	1	2	3	4
Home Care experience	N/A	1	2	3	4
Orthopedic	N/A	1	2	3	4
Neurologic	N/A	1	2	3	4
Vestibular	N/A	1	2	3	4
Geriatrics	N/A	1	2	3	4
Lymphedema	N/A	1	2	3	4
Anodyne	N/A	1	2	3	4