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Certification Certificartion No. License Expiration Action
“Please rate your ability for the following duties, 0=No Experience, 5 = Very Experienced”

Duties / Rating 0 1 2 3 4 5
Standing Shower
Sitting Shower
Bed Bath
Tub Bath
Shaving
Oral Care
Grooming
Skin Care
Perineum care
Toileting
Transfers
Dressing
Tube Feeding
Assist w/ exercise regimen
Meal preparation
Medication reminders
Ambulation assistance
Cleaning
Laundry
Change linen
Equipment / Rating 0 1 2 3 4 5
Transfer Board
Hoyer lift
Gait belt
Hospital bed
Wheel chair
Oxygen concentrator
Walker
Bedside commode
Nebulizer
Shower chair
Cane
Disease / Rating 0 1 2 3 4 5
Alzheimer's
Diabetes
Parkinson's
Heart Condition
Multiple Sclerosis
Stroke
Cancer
Osteoporosis
Asthma
Developmental Disabilities
COPD
HIV
Dementia
Arthritis
Aphasia



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