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Speech Language Therapy Skills Checklist

Name
Phone Number
Email Address

Please rate your experience / frequency (within the last year) using the following scale
(check the appropriate boxes below):

1 - No Experience / Theory Only
2 - Limited Experience / Need Review
3 - Frequent Experience / May Need Some Review
4 - Experienced / Perform Well

1 - Observed Only / Never Done
2 - Rarely Done (<6 times/year)
3 - Occasionally Done (1 - 2 times/month)
4 - Frequently Done (daily or weekly)

	Experience				Frequency
GENERAL SKILLS	1	2	3	4	1	2	3	4
Universal Precautions
Working with the Patient in Isolation
Working with a Patient in Restraints
Patient/Family Teaching
Electronic Documentation
AGE SPECIFIC COMPETENCY	1	2	3	4	1	2	3	4
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School age child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)
PATIENT POPULATIONS/DISORDERS	1	2	3	4	1	2	3	4
TIA/CVA
Coma Stimulation
Learning Disabilities/Early Intervention
Traumatic Brain Injury
Hearing Impairment/Loss
Aphasia
Apraxia
Progressive Neurologic Disease
Muscular Dystrophy
Multiple Sclerosis
ALS (Lou Gehrig's Disease)
Anoxia
Dysarthria
Cleft Palate
Feeding Disorders
Dementia/Alzheimers
Autism
Parkinsons
Fluency
Adult Mental Retardation (Mild-Moderate)
Adult Mental Retardation (Severe-Profound)
Pediatric Mental Retardation (Mild-Moderate)
Pediatric Mental Retardation (Severe-Profound)
DYSPHAGIA	1	2	3	4	1	2	3	4
Bedside Swallow Evaulation
Modified Barium Swallow Study
Thermal Simulation
Thickening Agents
Compensatory Techniques
Laryngectomy
Tracheostomy
Ventilator
Assisted Ventilator
Dependent Ventilator
SCREENING FOR	1	2	3	4	1	2	3	4
Attention Span
Expressive/Receptive Skills
Memory
Ability to Follow Directions
Oral Motor Movement
Auditory Capability

	Experience				Frequency
ASSESSMENT	1	2	3	4	1	2	3	4
Porch Index of Communicative Abilities
Minnesota Test for Differential Diagnosis of Aphasis
Boston Diagnostic Aphasia Examination
Boston Assessment of Severe Aphasia
Western Aphasia Battery
Rehab Institute of Chicago Evaluation of Communication
Reading Comprehension Battery for Aphasia
Aphasia Language Performance Scale
Communication Ability for Daily Living
Ross Information Processing Assessment
Detroit
Token
Cervical Auscultation
Pure Tone Screening
Augmentative Devices
Blue Dye Test
Video Fluroscopy
Video Stroboscopic Voice Evaluation
Fiberoptic Voice Evaluation
TREATMENT/EQUIPMENT	1	2	3	4	1	2	3	4
Individual
Group
Co-Treatment
Community Re-Entry
Vital Stimulation
Cognitive Training
Safety Awareness
Total Communication
Computer
Behavior Modification
Auditory Rehabilitation/Hearing Aids
Augmentative Communication
Electronic Devices
Communication Boards
Memory Aids
Functional Maintenance
Feeding Equipment
REGULATIONS / DOCUMENTATION	1	2	3	4	1	2	3	4
Medicare
Medi-Cal
Omnibus Budget Reconciliation Act
FIMS (Sports Medicine)
RUG Levels
Home Health Documentation
SETTINGS	1	2	3	4	1	2	3	4
Acute Care
Rehabilitation - Acute
Rehabilitation - Long Term
Sports Medicine
Children's Hospital - Acute Care
Children's Hospital - Rehab
School
Home Health
Physician's Office
Skilled Nursing Facility
Day Treatment Center
Early Intervention

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the indivdual completing this form. I hereby authorize Texas Select Staffing to release this Skills Checklist to its client facilities for consideration of employment as a contractor at those facilities.