Speech Language Pathologist Skills Checklist

Requested by: *

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Acute care	123
Children’s hospital	123
Daily treatment center	123
Home health care	123
Inpatient acute rehab	123
Neonatal intensive care	123
Outpatient/outpatient community re-entry	123
Pediatrics	123
Psychiatric hospital	123
Private practice	123
School setting	123
Early intervention	123
Skilled nursing facility	123

PATIENT POPULATIONS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Geriatrics	123
Hearing impaired	123
Learning disabilities	123
Pediatrics/school age	123
Progressive neurologic disease	123
Trachs/ventilators	123
Transient Ischemic Attach (TIA)	123
Traumatic brain injury	123
Voice/laryngectomy	123

ASSESSMENT TOOLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Boston assessment of severe aphasia	123
Boston diagnostic aphasia examination	123
Minnesota test for differential diagnosis of aphasia	123
Informal testing	123
Porch index of communicative abilities	123
Reading comprehension battery for aphasia	123
Ross information processing assessment-geriatric	123
Western aphasia battery	123
Bedside swallow evaluation	123
Blue dye test	123
Cervical auscultation	123
Fiber endoscopic evaluation study	123
Modified barium swallow study	123
Rehab Institute of Chicago evaluation of communication	123
Augmentative devices	123
Pure tone screening	123

TYPES OF DISORDERS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Aphasia	123
Apraxia	123
Autism	123
Cleft palate	123
CVA/stroke	123
Fluency	123
Dementia/alzheimers	123
Dysarthria	123
Dysphagia	123
Hearing loss	123
Learning disabilities	123
Traumatic brain injury	123

TREATMENT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Augmentative devices	123
Behavior modification	123
Cognitive training	123
Community re-entry	123
Computer	123
Co-treatment	123
Group	123
Individual	123
Safety awareness	123
Total communication	123
Vital stimulation	123
Dysphagia across the age-spectrum	123

REGULATIONS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

FIMS	123
Medi-Cal	123
Medicare	123
Omnibus budget reconciliation	123
RUG levels	123

GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Patient/family teaching	123
Patients in isolation	123
Patients in restraints	123
Initial evaluation	123
Lift/transfer devices	123
Specialty beds	123
End of life care/palliative care	123

COMPUTERIZED CHARTING:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Cerner	123
EPIC	123
McKesson	123
Meditech	123

NATIONAL PATIENT SAFETY GOALS:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Accurate patient identification	123
Effective communication	123
Pain assessment & management	123
Infection control	123
Universal precautions	123
Care of patients in isolation	123
Minimize risk of falls	123
Prevention of pressure ulcers	123

AGE-SPECIFIC COMPETENCIES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Infant (birth to 1 year)	123
Toddler (ages 1-3 years)	123
Preschooler (ages 3-5 years)	123
Childhood (ages 6-12 years)	123
Adolescents (ages 12-21 years)	123
Young Adults (ages 21-39 years)	123
Adults (ages 40-64 years)	123
Older Adults (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *