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SPEECH & LANGUAGE PATHOLOGIST

SKILLS/PROFICIENCY INVENTORY

Please print this out and send or fax the completed form to us

Circle one:     SLP              CFY

                                                     

NAME: _________________________________________________________________

                        First                             Middle                                Last

 

DIRECTIONS

By completing this checklist to the best of your ability, you will help us match your skills and the areas of interest with our available assignments. Please place a check (Ö) in the column that most accurately describes your level of experience with each skill.

 

EXPERIENCE LEVELS

1  = Very Experienced

2  = Experienced

3  = Some Experience

4  = No Experience

Ped- Pediatric Experience

Adult- Adult Experience

 

 

 

 

CLINICAL SETTINGS

1

2

3

4

Ped

Adult

Home Health

 

 

 

 

 

 

Hospital

 

 

 

 

 

 

Outpatient Clinic

 

 

 

 

 

 

Private

 

 

 

 

 

 

Private School

 

 

 

 

 

 

Public School

 

 

 

 

 

 

Skilled Nursing Facility

 

 

 

 

 

 

COMMUNICATION DISORDERS

 

 

 

 

 

 

ADD/ADHD

 

 

 

 

 

 

ALS

 

 

 

 

 

 

Alzheimer’s ( Dementia)

 

 

 

 

 

 

Aphasia

 

 

 

 

 

 

Apraxia

 

 

 

 

 

 

Articulation

 

 

 

 

 

 

Autism Spectrum Disorders

 

 

 

 

 

 

Cerebral Palsy

 

 

 

 

 

 

Cleft Palate

 

 

 

 

 

 

CVA

 

 

 

 

 

 

Dysarthria

 

 

 

 

 

 

Feeding Disorders

 

 

 

 

 

 

Fluency

 

 

 

 

 

 

Head Trauma

 

 

 

 

 

 

Hearing Impaired

 

 

 

 

 

 

Language Disorders

 

 

 

 

 

 

Laryngetomy

 

 

 

 

 

 

 

 

COMMUNICATION DISORDERS

 

1

 

2

 

3

 

4

 

Ped

 

Adult

Learning Disability

 

 

 

 

 

 

Low Level Functioning Patients

 

 

 

 

 

 

Mental Retardation

 

 

 

 

 

 

Multi-Handicapped

 

 

 

 

 

 

Non-Oral

 

 

 

 

 

 

Parkinson’s

 

 

 

 

 

 

PDD

 

 

 

 

 

 

Phonological Disorders

 

 

 

 

 

 

Trachs

 

 

 

 

 

 

Traumatic Brain Inquiry

 

 

 

 

 

 

Ventilator Dependent Patients