SLP SKILLS EVALUATION #2
SLP SKILLS EVALUATION #2
Personal Information
Name
*
First
Last
Title / Specialty
*
Email
*
Phone
-
(###)
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###
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Work Settings
Acute Care
No Experience
Some Experience
Very Experienced
Community Re-Entry
No Experience
Some Experience
Very Experienced
Home Health
No Experience
Some Experience
Very Experienced
Outpatient Clinic
No Experience
Some Experience
Very Experienced
Pediatric Rehab
No Experience
Some Experience
Very Experienced
Psychiatric
No Experience
Some Experience
Very Experienced
Rehab Hospital
No Experience
Some Experience
Very Experienced
Rehab Unit in Hospital
No Experience
Some Experience
Very Experienced
School System
No Experience
Some Experience
Very Experienced
Skilled Nursing Facility
No Experience
Some Experience
Very Experienced
Adaptive Equipment
Assessment
No Experience
Some Experience
Very Experienced
Augmentative Communication
No Experience
Some Experience
Very Experienced
Computer-Based Treatment
No Experience
Some Experience
Very Experienced
Adaptive Microswitches
No Experience
Some Experience
Very Experienced
Pediatrics
Cerebral Palsy
No Experience
Some Experience
Very Experienced
Early Intervention
No Experience
Some Experience
Very Experienced
Learning Language Disabilities
No Experience
Some Experience
Very Experienced
Mental Retardation
No Experience
Some Experience
Very Experienced
NDT for Speech
No Experience
Some Experience
Very Experienced
Speech / Language / Hearing Disabilities
Cleft Palate
No Experience
Some Experience
Very Experienced
Cognitive Rehab
No Experience
Some Experience
Very Experienced
Coma Stimulation
No Experience
Some Experience
Very Experienced
CVA Stroke Rehab
No Experience
Some Experience
Very Experienced
Fluency Stuttering
No Experience
Some Experience
Very Experienced
Head Injury
No Experience
Some Experience
Very Experienced
Hearing Impaired
No Experience
Some Experience
Very Experienced
Laryngectomy
No Experience
Some Experience
Very Experienced
Neurological
No Experience
Some Experience
Very Experienced
Voice
No Experience
Some Experience
Very Experienced
Other Skills
Accent Reduction
No Experience
Some Experience
Very Experienced
Accent Reduction
No Experience
Some Experience
Very Experienced
Aural Rehabilitation / Speech Reading
No Experience
Some Experience
Very Experienced
Biofeedback – EMG
No Experience
Some Experience
Very Experienced
Cognitive Assessment
No Experience
Some Experience
Very Experienced
Co-Treatment with Occupational Therapy
No Experience
Some Experience
Very Experienced
Co-Treatment with Physical Therapy
No Experience
Some Experience
Very Experienced
Family Education
No Experience
Some Experience
Very Experienced
Group Activities
No Experience
Some Experience
Very Experienced
In Service Education
No Experience
Some Experience
Very Experienced
Myofunctional Therapy
No Experience
Some Experience
Very Experienced
Prosthetics – Cleft Palate
No Experience
Some Experience
Very Experienced
Rehab Feeding Group
No Experience
Some Experience
Very Experienced
Sign Language
No Experience
Some Experience
Very Experienced
Tracheostomy
No Experience
Some Experience
Very Experienced
Ventilator
No Experience
Some Experience
Very Experienced
Videofluoroscopy
No Experience
Some Experience
Very Experienced
FEEST
No Experience
Some Experience
Very Experienced
List additional procedures with which you have had significant experience:
