Speech Language Pathology Skills Checklist

First name: ___________________________ Middle Name: ___________________

Last Name: ___________________________ Last 4 of SSN# ___________________

Email Address: ____________________________ Phone # ___________________

Please indicate your level of experience based on No experience (1) to perform independently (4)

1. No theory and/or experience

2. Limited experience/need supervision and/or support

3. Experienced/minimal support needed to perform

4. Proficient/can perform independently

Work setting experiences: Please circle 1-4 next to each facility based on experience

1 2 3 4

Skilled Nursing

General Acute Care

Long Term Acute Care

Inpatient Rehabilitation Hospital

Outpatient Rehabilitation

Sports Medicine Clinic

Rehabilitation Clinic

Pediatric Inpatient/Outpatient

School System

Home Health Care

Psychiatric Care

Hand Therapy Clinic

Adaptive Equipment:

1 2 3 4

Assessment

Augmentative Communication

Computer-based treatment

Speech/Language/Hearing Disabilities

1 2 3 4

Cleft Palate

Cognitive Rehabilitation

Coma Stimulation

Stroke Rehabilitation

Dysphagia

Hearing impaired

Head Injury

Fluency and/or stuttering

Laryngectomy

Neurological

Voice

Cerebral Palsy

Autism Spectrum Disorder

Feeding Disorders

Learning Language Disabilities

Conditions:

1 2 3 4

ADD / ADHD

ALS

Anomia

Aphasia

Aphonia

Apraxia

Articulation

Auditory Comprehension

Augmentative / Alternative Communication

Bell’s Palsy

Birth Defects

Broca’s Aphasia

Global Aphasia

Degenerative Disease

Dementia / Alzheimer’s

Multiple Sclerosis

Muscle Energy Techniques

Muscular Dystrophy

Neurodevelopment Deficits

1 2 3 4

Neuromuscular Disease

Parkinson’s Disease

Phonological Disorders

Progressive Neurological Disease

Reading and Spelling Disorders

Sensory Integrative Deficits

Traumatic Brain Injury (TBI)

Voice Disorders

Wernicke’s Aphasia

Modalities, Equipments and Procedures:

1 2 3 4

Adaptive Equipment

Augmentative Devices

Bedside Swallow Evaluation

Behavior Modification

Cognitive Training

Communication Board / Devices

Community Re-entry

Compensatory Techniques

Computer

Feeding Equipment

Fiberoptic Voice Evaluation

Ventilator Dependent / Assisted

Video Fluoroscopy

FEEST

E-Stim Therapy

Vital Stimulation Therapy

Inservice Education

Myofunctional Therapy

Prosthetics - Cleft Palate

Rehab Feeding Group

Sign Language

Tracheostomy

Accent Reduction

Aural Rehab/Speech Reading

1 2 3 4

Biofeedback - EMG

Memory Aide

Nasal Cannula

Pasameur Valve

Safety Awareness

Thermal Stimulation

Thickening Agents

Trach Collar

Bedside Swallow Evaluation

Assessment Tools:

1 2 3 4

Boston Diagnostic Aphasia Examination

Cervical Auscultation

Fiber Endoscopic Evaluation Study

Minnesota Test for Differential Diagnosis

Aphasia

Modified Barium Swallow Study

Porch Index of Communicative Abilities

Reading Comprehension Battery for Aphasia

Western Aphasia Battery

Age Specific Competency:

1 2 3 4

Infant - (Birth to 1 Year)

Toddler (1-3 Years)

Preschool Child (3-5 Years)

School Age Child (5-12 Years)

Adolescent (12-18 Years)

Young Adult (18-44 Years)

Middle Age Adult (45-65 Years)

Senior Adult (Over 65 Years)

Settings: Years/Months

Acute Care

Inpatient Acute Rehab

1 2 3 4

Day Treatment Center

Skilled Nursing Facility

Home Health

Outpatient

Early Intervention

Pediatrics/School Age

Private Practice

Certification: Month, day, and year

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Please read and agree to the statements below by placing your initials at the end of the

statement.

I attest that the information provided is true and accurate to the best of my knowledge. I

hereby authorize Nationwide Therapy Group to release the Skills Checklist to the facilities

for placement purposes. _____

First Name: ___________________ Last Name: _______________________

Signature: ___________________ Date: _______________________ (Signature on File)