Speech Language Pathologist Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlyWork SettingsAcute care 1 2 3 4 Children’s hospital 1 2 3 4 Daily treatment center 1 2 3 4 Home health care 1 2 3 4 Inpatient acute rehab 1 2 3 4 Neonatal intensive care 1 2 3 4 Outpatient/outpatient community re-entry 1 2 3 4 Pediatrics 1 2 3 4 Psychiatric hospital 1 2 3 4 Private practice 1 2 3 4 School setting 1 2 3 4 Early intervention 1 2 3 4 Skilled nursing facility 1 2 3 4 Patient PopulationsGeriatrics 1 2 3 4 Hearing impaired 1 2 3 4 Learning disabilities 1 2 3 4 Pediatrics/school age 1 2 3 4 Progressive neurologic disease 1 2 3 4 Trachs/ventilators 1 2 3 4 Transient Ischemic Attach (TIA) 1 2 3 4 Traumatic brain injury 1 2 3 4 Voice/laryngectomy 1 2 3 4 Assessment ToolsBoston assessment of severe aphasia 1 2 3 4 Boston diagnostic aphasia examination 1 2 3 4 Minnesota test for diff erential diagnosis ofaphasia 1 2 3 4 Informal testing 1 2 3 4 Porch index of communicative abilities 1 2 3 4 Reading comprehension battery for aphasia 1 2 3 4 Ross information processing assessment-geriatric 1 2 3 4 Western aphasia battery 1 2 3 4 Bedside swallow evaluation 1 2 3 4 Blue dye test 1 2 3 4 Cervical auscultation 1 2 3 4 Fiber endoscopic evaluation study 1 2 3 4 Modified barium swallow study 1 2 3 4 Rehab Institute of Chicago evaluation of communication 1 2 3 4 Augmentative devices 1 2 3 4 Pure tone screening 1 2 3 4 Types of DisordersAphasia 1 2 3 4 Apraxia 1 2 3 4 Autism 1 2 3 4 Cleft palate 1 2 3 4 CVA/stroke 1 2 3 4 Fluency 1 2 3 4 Dementia/alzheimers 1 2 3 4 Dysarthria 1 2 3 4 Dysphagia 1 2 3 4 Hearing loss 1 2 3 4 Learning disabilities 1 2 3 4 Traumatic brain injury 1 2 3 4 TreatmentAugmentative devices 1 2 3 4 Behavior modification 1 2 3 4 Cognitive training 1 2 3 4 Community re-entry 1 2 3 4 Computer 1 2 3 4 Co-treatment 1 2 3 4 Group 1 2 3 4 Individual 1 2 3 4 Safety awareness 1 2 3 4 Total communication 1 2 3 4 Vital stimulation 1 2 3 4 Dysphagia across the age-spectrum 1 2 3 4 RegulationsFIMS 1 2 3 4 Medi-Cal 1 2 3 4 Medicare 1 2 3 4 Omnibus budget reconciliation 1 2 3 4 RUG levels 1 2 3 4 General SkillsPatient/family teaching 1 2 3 4 Patients in isolation 1 2 3 4 Patients in restraints 1 2 3 4 Initial evaluation 1 2 3 4 Lift/transfer devices 1 2 3 4 Specialty beds 1 2 3 4 End of life care/palliative care 1 2 3 4 Computerized ChartingCerner 1 2 3 4 EPIC 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 National Patient Safety GoalsAccurate patient identification 1 2 3 4 Effective communication 1 2 3 4 Pain assessment & management 1 2 3 4 Infection control 1 2 3 4 Universal precautions 1 2 3 4 Care of patients in isolation 1 2 3 4 Minimize risk of falls 1 2 3 4 Prevention of pressure ulcers 1 2 3 4 Age Specific CompetenciesInfant (birth to 1 year) 1 2 3 4 Toddler (ages 1-3 years) 1 2 3 4 Preschooler (ages 3-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 12-21 years) 1 2 3 4 Young Adults (ages 21-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Additional SkillsPlease list any Additional SkillsAdditional TrainingPlease list any Additional TrainingAdditional EquipmentPlease list any Additional EquipmentAuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Speech Language Pathologist Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
