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Speech/Language Pathology Skills Checklist

Please fill out and submit the online Skills Checklist below.

You can also click here to download a PDF version of this form to fill out offline, and mail or fax it to us.
Mail: Prime HealthCare Staffing - 27240 Haggerty Road, Suite E-15 - Farmington Hills MI 48331
Toll Free Fax: 866-992-0900

First Name:
Last Name:

Please indicate how many years/months of professional work experience you have in the following settings.
If you have no work experience in a category please indicate 0. If experience was in your clinicals/internship ONLY, indicate C.


GENERAL WORK SETTING EXPERIENCE
Setting Length

Setting

 Length Setting Length Setting Length
Hospital-General Acute NICU Preschool Community Program
Hospital-Trauma Acute Peds-Inpatient Elementary School Long Term Acute Care
Hospital-Sub-acute Peds Outpatient Ortho Secondary School Long Term Acute Care
Hospital-Inpatient Rehab Peds-Outpatient Developmental Home Health Adults Assisted Living
Hospital-Outpatient Early Intervention Home Health Peds University /College
Day Rehab Headstart Program Group Homes Research

Please use the key below for the remainder of this checklist. Check the appropriate box that best describes your skill level in each of the following categories:

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


AGE SPECIFIC PRACTICE
AREA A B C D E F AREA A B C D E F
Newborn (birth-30 days) School Age (5-12 years)
Infant (30 days-1 year) Adolescents (12-18 years)
Toddler (1-3 years) Adults
Preschooler (3-5 years) Geriatrics
A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


GENERAL EXPERIENCE
AREA
A
B
C
D
E
F
AREA
A
B
C
D
E
F
AIDS/HIV Dyspraxia
Anterior Lateral Sclerosis (ALS) Education-Family
Alzheimer's Education-Patient
Anoxia Impairments-Fluency
Aphasia Impairments-Hearing
Apraxia Impairments-Language
Brain Tumor Impairments-Voice
Cancer Laryngectomy
Cerebral Vascular Accident (CVA) Muscular Dystrophy
Cognitive Rehabilitation Muscular Sclerosis
Degenerative Disorders Neurodevelopmental Disorders
Dementia Progressive Neurological
Developmental Disabilities Spinal Cord Injury (SCI)
Documentation-MDS Student Supervision
Documentation-OBRA Tracheotomy
Documentation-RUGS Treatment Co-Treatment
Dysarthria Treatment-Group
Dysphagia Treatment-Individual
Ventilator Assisted /Dependent

Please use the key below for the remainder of this checklist. Check the appropriate box that best describes your skill level in each of the following categories:

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


TREATMENT TECHNIQUES/ASSESSMENTS/EVALUATIONS
AREA A B C D E F AREA A B C D E F
Adaptive Equipment Screening-Attention Span
Augmentative Device Screening- Expressive Language
Bedside Swallow Evaluation Screening-Following Directions
Behavior Modification Screening-Hearing
Communication Board Screening-Memory Skills
Compensatory Techniques Screening-Oral Motor Movement
Craniosacral Therapy Screening-Receptive Language
Feeding Techniques Screening-Speech
Fiberoptic Standardized Testing
Memory Aides Thermal Stimulation
Modified Barium Swallow Study Thickening Agents
NDT Videoscopy
Oral Motor Treatment VitalStim Therapy

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


PEDIATRICS
AREA A B C D E F AREA A B C D E F
ADD/ADHD Educational Model/School
Apraxia Emotionally Impaired
Articulation Fluency Impairment
Asperger's Syndrome Hearing Impairment
Autism Spectrum IEP Development
Behavioral Difficulties Language Impairment
Cerebral Palsy Medical Model/Private Practice/Outpatient
Cleft Palate NICU
Cognitively Impaired Physical Disabilities
Developmental Delay Sensory Processing Deficits/Sensory Motor
Down's Syndrome Stuttering
Dyspraxia Visually Impaired

A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach


PEDIATRIC ASSESSMENTS/EVALUATIONS/TECHNIQUES
AREA A B C D E F AREA A B C D E F
Adaptive Equipment Screening-Hearing
Augmentative Devices Screening-Feeding
Communication Boards Screening-Oral Motor
Feeding Techniques Screening-Speech
Neurodevelopmental Techniques (NDT) Sign Language
Oral Motor Techniques Standardized Tests
PECS Treatment-Co-treat/Group
Screening-Cognition Treatment-Individual
A. No experience B. Clinical experience only C. Intermittent/previous experience D. Less then 2 years of experience
E. 2+ years of experience F. 10+ years of experience/can teach

Please list any special certifications you have, and skills or comments that you feel would help us find the proper placement for you.
Please read the following before submitting this survey
I verify that this statement of my work experience is accurate to the best of my knowledge.

I give my permission to Prime HealthCare Staffing to use this information while making appropriate job placements for me.
I understand this may include releasing this information to potential customers, upon request, during the assignment process.

I have read and agree to the above statements.