Skills Checklist - SLP - Origin Travel Nurses

Skills Checklist - SLP

Name
First Last
Phone
Email
SETTING*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Acute
Rehab
Inpatient
Outpatient
Home Health
SNF
Schools
ADAPTIVE EQUIPMENT*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Assessments
Augmentative Communication
Computer-based Treatment/Adaptive Microswitches

SPEECH / LANGUAGE / HEARING DISABILITIES*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Feeding Disorders
Cleft Palate
Cognitive Rehab
Coma Stimulation
CVA / Stroke Rehab
Dysphagia
Fluency / Stuttering
Head Injury
Hearing Impaired
Laryngectomy
Neurological
Voice

PEDIATRICS*
Rarely Some Experience Proficient Trainer / Preceptor N/A
Cerebral Palsy
Early Intervention
Learning Language Disabilities
Mental Retardation
NDT for Speech

OTHER SKILLS*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Accent Reduction
Aural Rehabilitation / Speech Reading
Biofeedback-EMG
Cognitive Assessment
Co-Treatment with OT
Co-Treatment with PT
Family Education
Group Activities
In-service Education
Myofunctional Therapies
Prosthetics- Cleft Palate
Rehab Feeding Group
Sign Language
Tracheostomy
Ventilator
Videofluoroscopy
FEEST
Electronic Documentation

OTHER SKILLS - TYPES OF ELECTRONIC DOCUMENTATION:
(if applicable)

Age Group Experience*

	Rarely	Some Experience	Proficient	Trainer / Preceptor	N/A
Newborn (birth - 30 days)
Infant (30 days - 1 year)
Toddler (1 - 3 years)
Preschooler (3 - 5 years)
School Age (5 - 12 years)
Adolescents (12 - 18 years)
Young Adults (18 - 39 years)
Middle Adults (39-64 years)
Older Adults (64+ years)

Do you speak any languages other than English?*
- No
If yes, enter languages above, separated by commas.
Confirmation*
- I attest that the information I have given is both true and, to the best of my knowledge, represents an accurate self assessment of my professional skills and/or education.
Signature
Date
MM slash DD slash YYYY