Skills Checklist – SLP 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 Date Format: MM slash DD slash YYYY