Employee Name: Self Assessment Key: Evaluation Method Key: P Proficient DO Direct Observation SIM Simulation – – – N Needs Review CT Cognitive Testing CA Chart Audit – – – I Inexperienced (Scores) – COMPLETED BY EMPLOYEE COMPLETED BY EVALUATOR SELF COMP EVAL EVAL SKILL/KNOWLEDGE DATE DATE COMMENTS METHOD Yes No INITIALS Vital Signs* P N I Functional Muscle Testing P N I and ROM* ADLS* P N I IADLS* P N I Work Simplification/ P N I Energy Conservation/ Breathing Techniques Transfer/Mobility P N I Training* Neuromuscular Function P N I Testing/Re-education* Cognitive and Visual P N I Perceptual Skills Evaluation and Training* Fine/Gross Motor Control/ P N I Coordination Testing/ Training* Sensory Status P N I Testing/Training* Joint Protection P N I Orthotics/Splinting P N I Postural Control P N I Edema/Edema Control P N I Adaptive Equipment P N I Needs/Application* Home Program Develop./ P N I
Employee Name: Self Assessment Key: P – Proficient N – Needs Review I – Inexperienced Evaluation Method Key: DO – Direct Observation SIM – Simulation CT – Cognitive Testing CA – Chart Audit (Scores) COMPLETED BY EMPLOYEE COMPLETED BY EVALUATOR SKILL/KNOWLEDGE DATE SELF DATE COMP Yes No EVAL METHOD COMMENTS EVAL INITIALS Vital Signs* P N I Functional Muscle Testing and ROM* P N I ADLS* P N I IADLS* P N I Work Simplification/ Energy Conservation/ Breathing Techniques P N I Transfer/Mobility Training* P N I Neuromuscular Function Testing/Re-education* P N I Cognitive and Visual Perceptual Skills Evaluation and Training* P N I Fine/Gross Motor Control/ Coordination Testing/ Training* P N I Sensory Status Testing/Training* P N I Joint Protection P N I Orthotics/Splinting P N I Postural Control P N I Edema/Edema Control P N I Adaptive Equipment Needs/Application* P N I Home Program Develop./ P N I