COTA

OT/COTA

Name*
Full Name
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale:
No Experience
Theory or observation only during the past 12 months

Limited Experience
Performed less than 12 times within the past 12 months and may need a review

Experienced
Performed at least once per month within the past 12 months and may need minimal assistance

Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient

Therapy - Pediatrics

	No Experience	Limited Experience	Experienced	Highly Skilled
Articulation
Care of Child - Burn Care
Care of Child - Cerebral Palsy
Care of Child - Cystic Fibrosis
Care of Child - Early Intervention
Care of Child - Learning Disabilities
Care of Child - Mental Retardation - Mild
Care of Child - Mental Retardation - Moderate
Care of Child - Mental Retardation - Profound
Care of Child - Mental Retardation - Severe
Care of Child - Muscular Dystrophy
Care of Child - Spina Bifida
Care of Child - Traumatic Brain Injury
Critical Care Procedures
Fluency
Group Treatment
Hearing Impairments
Isolation Precautions
Language
Neurologic - Congenital Defects
Neurologic - Developmental Disabilities Sequencing Test
Neurologic - Head Injury
Neurologic - Neurodevelopmental Techniques
Neurologic - Sensory Integrative Deficits
Neurologic - Spinal Cord Injury
Neurologic - Visual Perceptual Disorders
Orthopedics - Birth Defects
Orthopedics - Developmental Diseases of Bone
Orthopedics - Fractures
Procedure/Treatment - Adaptive Equipment Assessment
Procedure/Treatment - Adaptive Equipment Training
Procedure/Treatment - CPM Machine
Procedure/Treatment - Dynamic Splints
Procedure/Treatment - Feeding
Procedure/Treatment - Hydrotherapy
Procedure/Treatment - Postural Balance Therapy
Procedure/Treatment - Resting Splints
Procedure/Treatment - Sensory Integration Techniques
Procedure/Treatment - Splinting - Hand
Procedure/Treatment - Splinting - Lower Extremity
Procedure/Treatment - Splinting - Wrist
Procedure/Treatment - Vision Therapy
Prosthetics - Lower Extremity Prosthetics
Prosthetics - Upper Extremity Prosthetics
Screenings
Tracheostomy
Burn Management
Cardiac Rehab
Care of Patient - Anoxia
Care of Patient - CVA
Care of Patient - Degenerative Disease
Care of Patient - Laryngectomy

General Therapy

	No Experience	Limited Experience	Experienced	Highly Skilled
Screenings
Tracheostomy
Burn Management
Cardiac Rehab
Care of Patient - Anoxia
Care of Patient - CVA
Care of Patient - Degenerative Disease
Care of Patient - Laryngectomy
Care of Patient - Mental Retardation - Mild
Care of Patient - Mental Retardation - Moderate
Care of Patient - Mental Retardation - Profound
Care of Patient - Mental Retardation - Severe
Care of Patient - Multiple Sclerosis
Care of Patient - Muscular Dystrophy
Care of Patient - Tracheotomy
Care of Patient - Traumatic Brain Injury
Care of Patient -Ventilator Dependent/Assisted
Fluency
Hearing Impairments
Neurologic - Adaptive Equipment - Wheelchair
Neurologic - Cognitive Disorders
Neurologic - Head Trauma
Neurologic - Neuromuscular Disease
Neurologic - Spinl Cord Injury
Neurologic - Stroke Rehabilitation
Orthopedic - Amputations
Orthopedic - Arthritis
Orthopedic - Back Injuries/Surgeries
Orthopedic - Fractures
Orthopedic - Hand Injury
Orthopedic - Hip Fractures/Injuries
Orthopedic - Knee Injuries
Orthopedic - Neck Injuries/Surgeries
Orthopedic - Osteoarthritis
Orthopedic - Post Operative Care
Orthopedic - Shoulder Injury
Orthopedic - TMJ
Orthopedic - Total Joint Replacement
Orthopedic - Upper Extremity Joint Replacement
Procedure/Treatment - Activities of Daily Living
Procedure/Treatment - Acupressure
Procedure/Treatment - Adaptive Equipment Assessment
Procedure/Treatment - Adaptive Equipment Training
Procedure/Treatment - Cervical Traction
Procedure/Treatment - Cognitive Techniques
Procedure/Treatment - Community Re-Entry
Procedure/Treatment - CPM Machine
Procedure/Treatment - Cranialsacral Techniques
Procedure/Treatment - Cryotherapy
Procedure/Treatment - Debridement
Procedure/Treatment - Diathermy
Procedure/Treatment - Electrical Stimulation
Procedure/Treatment - Exercise Programs
Procedure/Treatment - Extremity Mobilization
Procedure/Treatment - Feeding Techniques
Procedure/Treatment - Functional - Dynamic Splinting
Procedure/Treatment - Functional Capacity Evaluation
Procedure/Treatment - Gait Training
Procedure/Treatment - Group Treatment
Procedure/Treatment - Home Safety Evaluation
Procedure/Treatment - Hubbard Tank
Procedure/Treatment - Hydrotherapy
Procedure/Treatment - Iontophoresis
Procedure/Treatment - Joint Mobilization
Procedure/Treatment - Lumbar Tration
Procedure/Treatment - Massage
Procedure/Treatment - Muscle Energy Techniques
Procedure/Treatment - Myofacial Release
Procedure/Treatment - Neurodevelopmental Techniques
Procedure/Treatment - Phonophoresis
Procedure/Treatment - Postural Education
Procedure/Treatment - Soft Tissue Manipulation
Procedure/Treatment - Spinal Mobilization
Procedure/Treatment - Splinting - Elbow
Procedure/Treatment - Splinting - Hand
Procedure/Treatment - Splinting - Wrist
Procedure/Treatment - Sterilization Techniques
Procedure/Treatment - TENS
Procedure/Treatment - Therapeutic Pool
Procedure/Treatment - Transfers
Procedure/Treatment - Ultrasound
Procedure/Treatment - Vision Therapy
Procedure/Treatment - Whirlpool
Procedure/Treatment - Work Capacity Evaluation
Procedure/Treatment - Wound Management
Prosthetics - Above Knee
Prosthetics - Ankle/Foot Orthosis
Prosthetics - Below Knee
Screenings
Sign Language
Sports Medicine - Athletic Injuries
Sports Medicine - Biodex
Sports Medicine - Cybex
Sports Medicine - LIDO
Sports Medicine - Nautilus/Eagle
Sports Medicine - Orthotron
Sports Medicine - Taping
Voice

Therapy - Geriatrics

	No Experience	Limited Experience	Experienced	Highly Skilled
Burn Management
Cardiac Rehab
Cardiovascular Disease
Diabetes
Exercise Programs
Geriatric Psych
ICU Prodcedures
Neurologic - Adaptive Equipment - Wheelchair
Neurologic - Alzheimers/Dementia
Neurologic - Cognitive Disorders
Neurologic - Head Trauma
Neurologic - Neuromuscular Disease
Neurologic - Spinal Cord Injury
Neurologic - Stroke Rehabilitation
Orthopedic - Amputation
Orthopedic - Arthritis
Orthopedic - Back Injuries/Surgeries
Orthopedic - Fractures
Orthopedic - Hand Injuries
Orthopedic - Hip Fractures/Injuries
Orthopedic - Knee Injuries
Orthopedic - Neck Injuries/Surgeries
Orthopedic - Osteoarthritis
Orthopedic - Post Operative Care
Orthopedic - Shoulder Injury
Orthopedic - TMJ
Orthopedic - Total Hip Replacement
Orthopedic - Total Joint Replacement
Orthopedic - Total Knee Replacement
Orthopedic - Upper Extremity Joint Replacement
Pacemakers
Procedure / Treatment - Activities of Daily Living
Procedure / Treatment - Acupressure
Procedure / Treatment - Adaptive Equipment Assessment
Procedure / Treatment - Adaptive Equipment Training
Procedure / Treatment - Cervical Traction
Procedure / Treatment - Cognitive Rehab
Procedure / Treatment - CPM Machine
Procedure / Treatment - Cranialsacral Techniques
Procedure / Treatment - Cryotherapy
Procedure / Treatment - Diathermy
Procedure / Treatment - Documentation - Medicare A
Procedure / Treatment - Documentation - Medicare B
Procedure / Treatment - Documentation - State Healthcare
Procedure / Treatment - Electrical Stimulation
Procedure / Treatment - Extremity Mobilization
Procedure / Treatment - Feeding Techniques
Procedure / Treatment - Functional - Dynamic Splinting
Procedure / Treatment - Gait Training
Procedure / Treatment - Home Safety Evaluation
Procedure / Treatment - Hubbard Tank
Procedure / Treatment - Hydrotherapy
Procedure / Treatment - Lumbar Traction
Procedure / Treatment - Massage
Procedure / Treatment - Neurodevelopment Testing
Procedure / Treatment - Resting Splints
Procedure / Treatment - Spinal Mobilization
Procedure / Treatment - Splinting - Hand
Procedure / Treatment - Splinting - Wrist
Procedure / Treatment - Sterilization Techniques
Procedure / Treatment - TENS
Procedure / Treatment - Therapeutic Pool
Procedure / Treatment - Transfers
Procedure / Treatment - Ultrasound
Procedure / Treatment - Vision Therapy
Procedure / Treatment - Whirlpool
Procedure / Treatment - Wound Management
Prosthetics - Above Knee
Prosthetics - Ankle/Foot Orthosis
Prosthetics - Below Knee
Upper Extremity Prosthetics

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