Your Contact Information

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 care123
Children’s hospital123
Daily treatment center123
Home health care123
Inpatient acute rehab123
Neonatal intensive care123
Outpatient/outpatient community re-entry123
Pediatrics123
Psychiatric hospital123
Private practice123
School setting123
Early intervention123
Skilled nursing facility123
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
 *
Geriatrics123
Hearing impaired123
Learning disabilities123
Pediatrics/school age123
Progressive neurologic disease123
Trachs/ventilators123
Transient Ischemic Attach (TIA)123
Traumatic brain injury123
Voice/laryngectomy123
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 aphasia123
Boston diagnostic aphasia examination123
Minnesota test for differential diagnosis of aphasia123
Informal testing123
Porch index of communicative abilities123
Reading comprehension battery for aphasia123
Ross information processing assessment-geriatric123
Western aphasia battery123
Bedside swallow evaluation123
Blue dye test123
Cervical auscultation123
Fiber endoscopic evaluation study123
Modified barium swallow study123
Rehab Institute of Chicago evaluation of communication123
Augmentative devices123
Pure tone screening123
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
 *
Aphasia123
Apraxia123
Autism123
Cleft palate123
CVA/stroke123
Fluency123
Dementia/alzheimers123
Dysarthria123
Dysphagia123
Hearing loss123
Learning disabilities123
Traumatic brain injury123
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 devices123
Behavior modification123
Cognitive training123
Community re-entry123
Computer123
Co-treatment123
Group123
Individual123
Safety awareness123
Total communication123
Vital stimulation123
Dysphagia across the age-spectrum123
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
 *
FIMS123
Medi-Cal123
Medicare123
Omnibus budget reconciliation123
RUG levels123
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 teaching123
Patients in isolation123
Patients in restraints123
Initial evaluation123
Lift/transfer devices123
Specialty beds123
End of life care/palliative care123
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
 *
Cerner123
EPIC123
McKesson123
Meditech123
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 identification123
Effective communication123
Pain assessment & management123
Infection control123
Universal precautions123
Care of patients in isolation123
Minimize risk of falls123
Prevention of pressure ulcers123
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 *