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1 = No Experience 3 = Experienced
2 = Intermittent Experience 4 = Supervise and Teach

General Skills   1   2   3   4
Patient/Family Teaching
Patients in Isolation
Patients in Restraints
Electronic Documentation
Patient Populations   1   2   3   4
TIA
Learning Disabilities
Progressive Neurologic Disease
Traumatic Brain Injury
Hearing Impaired
Trachs/Ventilators
Pediatrics/School Age
Geriatrics
Voice/Laryngectomy
Assessment Tools   1   2   3   4
Porch Index of Communicative Abilities
Minnesota Test for Differential Diagnoses of Aphasia
Boston Diagnostic Aphasia Examination
Boston Assessment of Severe Aphasia
Ross Information Processing Assessment-Geriatric
Western Aphasia Battery
Rehab Institute of Chicago Evaluation of Communication
Reading Comprehension Battery for Aphasia
Bedside swallow Evaluation
Modified Barium Swallow Study
Fiber Endoscopic Evaluation Study F.E.E.S
Cervical Auscultation
Pure Tone Screening
Augmentative Devices
Blue Dye Test
Informal Testing
Types of Disorders   1   2   3   4
Aphasia
Apraxia
Dysarthria
Hearing Loss
Dysphagia
Autism
Learning Disabilities
Dementia/Alzheimers
Cleft Palate
Fluency
Traumatic Brain Injury
CVA/stroke
Treatment   1   2   3   4
Individual
Group
Co-Treatment
Community Re-entry
Augmentative Devices
Vital Stimulation
Cognitive Training
Safety Awareness
Dysphagia
Total Communication
Computer
Behavior Modification
Regulations   1   2   3   4
Omnibus Budget Reconciliation Act
Act
Medicare
Medi-Cal
FIMS
RUG Levels
Settings   1   2   3   4
Acute Care
Inpatient Acute Rehab
Day Treatment Center
Skilled Nursing Facility
Home Health
Outpatient
Early Intervention
Pediatrics/School Age
Private Practice

Other Skills
1
2
3
4

Other:

Other:

Other:


 
Inpatient
Outpatient
Areas of Experience
Months
Years
Months
Years

General acute care

Rehabilitation hospital

Sports Medicine clinic

Children's hospital

School system

Home Health Care

Physician's Office

Skilled nursing facility

 

ASHA Certification

Yes   No 

date (mm/yy)

CPR Certification

Yes   No 

date (mm/yy)

Comments :
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