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Speech Language Therapy Skills

Using the scale(s) below, please complete the following skill self assessment based upon your experience within the last 2 years.

* * *

*Indicates Required Fields

	PROFICIENCY	FREQUENCY
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KEY
Proficiency : [1] None [2] Intermittent [3] Experienced [4] Supervise / Teach
Frequency : [1] Never / Observation only [2] Less Than 6 Months [3] Twice / Month [4] Daily - Weekly
Patient Groups
Infant	1 2 3 4	1 2 3 4
Pediatrics	1 2 3 4	1 2 3 4
Adolescent	1 2 3 4	1 2 3 4
Adult	1 2 3 4	1 2 3 4
Geriatric	1 2 3 4	1 2 3 4
Specialty Areas
Acute Care	1 2 3 4	1 2 3 4
Intensive Care	1 2 3 4	1 2 3 4
Neonatology	1 2 3 4	1 2 3 4
Pediatric Intensive Care	1 2 3 4	1 2 3 4
Cerebral Vascular Accident	1 2 3 4	1 2 3 4
Dysphasia	1 2 3 4	1 2 3 4
Head Injury	1 2 3 4	1 2 3 4
Skilled Nursing
Restorative Nursing	1 2 3 4	1 2 3 4
Long Term Care	1 2 3 4	1 2 3 4
Geriatric Rehabilitation	1 2 3 4	1 2 3 4
Dysphasia	1 2 3 4	1 2 3 4
Cerebral Vascular Accident	1 2 3 4	1 2 3 4
Parkinson's Disease	1 2 3 4	1 2 3 4
Multiple Sclerosis	1 2 3 4	1 2 3 4
Head Injury	1 2 3 4	1 2 3 4
Home Health
CVA	1 2 3 4	1 2 3 4
Head Injury	1 2 3 4	1 2 3 4
Pediatric	1 2 3 4	1 2 3 4
MRDD / Group Home	1 2 3 4	1 2 3 4
Assisted Living	1 2 3 4	1 2 3 4
Outpatient
Laryngectomy	1 2 3 4	1 2 3 4
Voice Disorders	1 2 3 4	1 2 3 4
Augmentative Disorders	1 2 3 4	1 2 3 4
Head Injury	1 2 3 4	1 2 3 4
Fluency Disorders	1 2 3 4	1 2 3 4
Pediatrics
Acute	1 2 3 4	1 2 3 4
Home Health	1 2 3 4	1 2 3 4
Outpatient	1 2 3 4	1 2 3 4
Rehabilitation	1 2 3 4	1 2 3 4
School System	1 2 3 4	1 2 3 4
Developmental Delay	1 2 3 4	1 2 3 4
Dysphasia	1 2 3 4	1 2 3 4
Rehabilitation
CVA	1 2 3 4	1 2 3 4
Head Injury	1 2 3 4	1 2 3 4
Equipment and Procedures
Electronic Augmentation	1 2 3 4	1 2 3 4
Manual Augmentation	1 2 3 4	1 2 3 4
Cognitive Evaluation and Treat	1 2 3 4	1 2 3 4
Dysphasia Treatment	1 2 3 4	1 2 3 4
Tracheotomy	1 2 3 4	1 2 3 4
Hearing Screens	1 2 3 4	1 2 3 4
Sensory Stimulation	1 2 3 4	1 2 3 4
Ventilator	1 2 3 4	1 2 3 4
Video Fluoroscopy	1 2 3 4	1 2 3 4
Voice Evaluation and Treatment	1 2 3 4	1 2 3 4
Voice Restoration Techniques	1 2 3 4	1 2 3 4
Family Education	1 2 3 4	1 2 3 4
700 Series	1 2 3 4	1 2 3 4
PPS	1 2 3 4	1 2 3 4
Medicare A	1 2 3 4	1 2 3 4
Medicare B	1 2 3 4	1 2 3 4
Medicaid	1 2 3 4	1 2 3 4
Managed Care	1 2 3 4	1 2 3 4
CQI	1 2 3 4	1 2 3 4
Management	1 2 3 4	1 2 3 4
Experience in the Following Settings
General Acute Care Hospital	1 2 3 4	1 2 3 4
Pediatric Hospital or Clinic	1 2 3 4	1 2 3 4
Rehabilitation Hospital	1 2 3 4	1 2 3 4
Home Health	1 2 3 4	1 2 3 4
SNF	1 2 3 4	1 2 3 4
Long Term Care Facility	1 2 3 4	1 2 3 4
Private Practice	1 2 3 4	1 2 3 4
Outpatient Orthopedic Clinic	1 2 3 4	1 2 3 4
Hospice Program	1 2 3 4	1 2 3 4
Corporate/Industrial Medical Center	1 2 3 4	1 2 3 4
Work/Occupational Health	1 2 3 4	1 2 3 4
Physician's Office	1 2 3 4	1 2 3 4
Fitness Center	1 2 3 4	1 2 3 4
Sports Injury Center	1 2 3 4	1 2 3 4
Academic Research Center	1 2 3 4	1 2 3 4
Pre-School System	1 2 3 4	1 2 3 4
Primary School System	1 2 3 4	1 2 3 4
Secondary School System	1 2 3 4	1 2 3 4
Vocational Rehab	1 2 3 4	1 2 3 4
Case Management Department	1 2 3 4	1 2 3 4
Clinical Instructor	1 2 3 4	1 2 3 4
Inservice Education	1 2 3 4	1 2 3 4
Age group Settings
Newborn	1 2 3 4	1 2 3 4
0-3 Years	1 2 3 4	1 2 3 4
3-5 Years	1 2 3 4	1 2 3 4
5-12 Years	1 2 3 4	1 2 3 4
12-18 Years	1 2 3 4	1 2 3 4
Adult	1 2 3 4	1 2 3 4
Geriatric	1 2 3 4	1 2 3 4
By affixing the last 4 digit of the SSN, I certify that I have electronically completed this skills checklist on the date shown below.
Last 4 digit of SSN	Date

INSTANT APPLICATION

Speech Language Therapy Skills

KEY

PROFICIENCY

FREQUENCY