RN Orthopedics One program to handle all talent management needs from acquisition to development Personal Information HiddenOverall ScoreName(Required) First Middle Last Last 4 Digits of Social Security Number Email(Required) HiddenDate MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlySkills-Casts-Fiberglass/ SyntheticSkills-Casts-Fiberglass/ Synthetic(Required) 1 2 3 4 Long arm in flexion with ulnar deviation w/3 point molding(Required) 1 2 3 4 Long arm pronation or supination(Required) 1 2 3 4 Short arm in neutral position(Required) 1 2 3 4 Short arm in flexion with ulnar deviation with 3 point molding(Required) 1 2 3 4 Short leg walking in neutral position(Required) 1 2 3 4 Short leg walking in equines(Required) 1 2 3 4 Short leg non weight bearing in equines(Required) 1 2 3 4 Short leg non weight bearing in neutral position(Required) 1 2 3 4 P.T.B. with correct molding(Required) 1 2 3 4 Long leg walker(Required) 1 2 3 4 Cylinder cast(Required) 1 2 3 4 Long leg non weight bearing in neutral position with correct knee flexion(Required) 1 2 3 4 Long leg non weight bearing with molding for widened mortise(Required) 1 2 3 4 Toe plates applied to short and long leg casts(Required) 1 2 3 4 Gauntlet with outrigger-hand(Required) 1 2 3 4 Gauntlet with outrigger and molding-hand(Required) 1 2 3 4 Long arm navicular thumb spica(Required) 1 2 3 4 Long arm thumb spica(Required) 1 2 3 4 Cast saw: Remove cast(Required) 1 2 3 4 Trim casts(Required) 1 2 3 4 Wedging(Required) 1 2 3 4 Remove and replace cast blades(Required) 1 2 3 4 Window casts(Required) 1 2 3 4 Univalve casts(Required) 1 2 3 4 Other(Required) 1 2 3 4 Skills-SplintsShort leg posterior(Required) 1 2 3 4 Short leg sugar tong(Required) 1 2 3 4 Thumb spica(Required) 1 2 3 4 Hand muff splint(Required) 1 2 3 4 Foot muff splint(Required) 1 2 3 4 Gutter splint lateral and medial(Required) 1 2 3 4 Short arm volar(Required) 1 2 3 4 Long arm posterior with side walls(Required) 1 2 3 4 Sugar tong double long arm(Required) 1 2 3 4 Sugar tong short arm(Required) 1 2 3 4 Other(Required) 1 2 3 4 Braces, ImmobilizersWrist brace(Required) 1 2 3 4 Ace bandage(Required) 1 2 3 4 Shoulder immobilizer(Required) 1 2 3 4 Slings(Required) 1 2 3 4 Hinged knee brace(Required) 1 2 3 4 Velcro knee brace(Required) 1 2 3 4 Cervical collar - Hard(Required) 1 2 3 4 Cervical collar - Soft(Required) 1 2 3 4 Other(Required) 1 2 3 4 Traction Assist in the management of anesthesia when indicated.Bucks(Required) 1 2 3 4 Bryant’s(Required) 1 2 3 4 Overhead bed frame(Required) 1 2 3 4 Splint Russells(Required) 1 2 3 4 Balanced suspension(Required) 1 2 3 4 Assist MD with fracture reduction(Required) 1 2 3 4 Cervical(Required) 1 2 3 4 Other(Required) 1 2 3 4 Physical TherapyRange of motion exercises(Required) 1 2 3 4 Gait training(Required) 1 2 3 4 Crutches and canes(Required) 1 2 3 4 Crutches and canes - Fitting(Required) 1 2 3 4 Crutches and canes - Instructions(Required) 1 2 3 4 Other(Required) 1 2 3 4 MiscellaneousRemoval of sutures(Required) 1 2 3 4 Making various casts and molds(Required) 1 2 3 4 Preparing plaster of Paris mix(Required) 1 2 3 4 Make alterations to casts to alleviate pressure points(Required) 1 2 3 4 Assisting with research projects(Required) 1 2 3 4 Assist with skin grafts(Required) 1 2 3 4 Assist with stump revisions(Required) 1 2 3 4 Assist with pin insertions(Required) 1 2 3 4 Assist with debridements(Required) 1 2 3 4 Application of Minerva/ Halo jacket(Required) 1 2 3 4 Sterile dressing techniques(Required) 1 2 3 4 Removal of orthopedic devices(Required) 1 2 3 4 Other(Required) 1 2 3 4 Age Specific:Please indicate the frequency with which you provide care for each age group: Infant (Birth to 1 year)(Required) 1 2 3 4 Toddler (1-3 years)(Required) 1 2 3 4 Pre-school (3-6 years)(Required) 1 2 3 4 School Age (6-12 years)(Required) 1 2 3 4 Adolescent ( 12-18 years)(Required) 1 2 3 4 Young Adult ( 18-30 years)(Required) 1 2 3 4 Mature Adult (30-60 years)(Required) 1 2 3 4 Elderly (>60 years)(Required) 1 2 3 4 AuthorizationsLegal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. 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In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. 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