Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days corrected age)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Electronic Documentation
    Ability to Perform a Dynamic Assessment
    Universal Precautions
    Working with patients in isolation
    Working with patients in restraints
    Patient/Family teaching
    Patient Identification
    Specialty beds
    End of life care/palliative care
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Other Electronic Documentation:
    SETTINGS
    Acute Care/ Hospital
    Rehabilitation - Acute
    Rehabilitation - Long Term
    Home Health
    Outpatient
    Day Treatment Centers
    School
    Skilled Nursing Facility
    Physician's Office
    Early Intervention
    PATIENT POPULATIONS/DISORDERS
    Alzheimer's
    Augmentative and Alternative Communication - Low Tech
    Augmentative and Alternative Communication - High Tech
    Aphasia
    Autism
    Adult Intellectual Disability (Mild-Moderate)
    Adult Intellectual Disability (Severe-Profound)
    Pediatric Intellectual Disability (Mild-Moderate)
    Pediatric Intellectual Disability (Severe-Profound)
    Traumatic Brain Injury/Cognitive Communication - Attention
    Traumatic Brain Injury/Cognitive Communication - Memory
    Traumatic Brain Injury/Cognitive Communication - Problem Solving
    Traumatic Brain Injury/Cognitive Communication - Executive Functioning
    Choking
    Cleft Lip and Palate
    Cancer
    Cerebral Palsy
    COPD
    Dementia
    Down Syndrome
    Dysarthria
    Dysphagia
    Feeding Disorders - Pediatric Feeding Disorders
    Feeding Disorders - Pediatric Dysphagia
    Feeding Disorders - Adult Dysphagia
    Fluency Disorder
    GERD
    Hearing Impairment/Auditory Rehabilitation or Habilitation
    Head Trauma/Injury
    Language Disorder - Prelinguistic language impairment
    Language Disorder - Pre-school language impairment
    Language Disorder - School age language impairment
    Language Disorder - Expressive and/or Receptive language impairment
    Modified Barium Swallow Studies
    Motor Speech Disorders - Apraxia
    Motor Speech Disorders - Dysarthia
    Multiple Sclerosis
    Parkinson's Disease
    Progressive Neurological Disease
    Speech Sound Disorder - Articulation
    Speech Sound Disorder - Phonology
    Sjogren's Syndrome
    Stuttering
    Trachs
    Ventilator Dependent patients
    Voice Disorder - Laryngectomy
    Voice Disorder - Parkinson’s Disease
    Voice Disorder - Vocal Nodules
    ASSESSMENT
    Aphasia Language Performance Scale
    Augmentative Devices
    Bayley Scale of Infant and Toddler Development
    Bedside Swallow Testing
    Boston Speech Therapy
    Blue Dye Test
    Cervical Auscultation
    CADL ( Communication Ability for Daily Living)
    Clinical Evaluation of Language Functioning (CELF)
    Cognitive Linguistic Test
    Comprehensive Assessment of Spoken Language
    DAS-II
    FEES ( Flexible Endoscopic Evaluation of Swallowing)
    Fiber optic Voice Evaluation
    Functional Assessment of Communication Skills
    Goldman Fristoe Test of Articulation
    Modified Barium Swallow Study
    Minnesota Schuell's Stimulation Approach
    PICA (Porch Index of Communication Ability)
    Preschool Language Scale
    Pure Tone Screening
    Reading comprehension battery for aphasia
    Ross information processing assessment - geriatric
    Rossetti Infant-Toddler Language Scale
    Rehabilitation Institute of Chicago evaluation of communication
    Test of Language Development
    TILL Test of Integrated Language and Literacy Skills
    Western Aphasia Battery
    TREATMENT
    Individual
    Co-Treatment
    Inpatient
    Outpatient
    Cognitive Training
    Community Re-Entry
    Computer
    Group
    Dysphagia management
    Feeding Equipment
    Memory Aids
    Safety Awareness
    Sign Language
    Total Communication
    Vital Stimulation
    REGULATIONS/DOCUMENTATION
    FIMS
    Home Health Documentation
    Medi-Cal
    Medicare
    Omnibus budget reconciliation
    RUG levels
    EQUIPMENT
    Adaptive Communication Switch
    Audio/Video Recorder
    Electroglottograph
    Laryngograph
    Mirror
    Positioning Devices (Rifton Chairs, Tumbleforms)
    Prosthetics
    Reinforcers
    Stroboscopes
    Switches
    Tongue Depressor
    Voice Synthesizer