Full Name :
Phone :
Email :

1 = No Experience		3 = Experienced
2 = Intermittent Experience		4 = Supervise and Teach

Adult	1	2	3	4
Adult CVA
Adult Coma Stimulation
Adult TBI
Adult Degenerative Diseases
Adult Mental Retardation
Adult Mental Retardation Mild
Adult Mental Retardation Moderate
Adult Mental Retardation Severe
Adult Mental Retardation Profound
Adult Anoxia
Adult Layngectomy
Adult Tracheotomy
Adult Ventilator Dependent
Adult Fluency
Adult Voice
Adult Screenings
Adult Hearing Impairments
Adult Sign Language
Pediatrics	1	2	3	4
Pediatric CVA
Pediatric Coma Stimulation
Pediatric TBI
Pediatric Degenerative Diseases
Pediatric Mental Retardation
Pediatric Mental Retardation Mild
Pediatric Mental Retardation Moderate
Pediatric Mental Retardation Severe
Pediatric Mental Retardation Profound
Pediatric Anoxia
PedLayngectomy
Pediatric Tracheotomy
Pediatric Ventilator Dependent
Pediatric Fluency
Pediatric Voice
Pediatric Screenings
Pediatric Hearing Impairments
Pediatric Sign Language
Dysphasia	1	2	3	4
Bedside Swallow Evaluation
Barium Swallow
Thermal Simulation
Thickening Agents
Compensatory Techniquest
Laryngectomy
Tracheotomy
Ventilator
Assisted Ventilator
Dependent Ventilator
Adaptive Equipment	1	2	3	4
Communication Board
Augmentative Communication
Alternative Communication Devices
Memory Aide
Other	1	2	3	4
Medicare Documentation
Home Health Documentation
Family Education
In-service Training
Transfer Training
Video stroboscopic Voice Evaluation
Fiber optic Voice Evaluation
Aural Rehabilitation
Functional Maintenance
Video Fluoroscopy
Multiple Sclerosis
Muscular Dystrophy
Other Skills Rating 1
Other Skills Rating 2
Other Skills Rating 3

Other Skills

Other:
Other:
Other:

	Inpatient		Outpatient
Areas of Experience	Months	Years	Month	Year
General acute care
Rehabilitation hospital
Sports Medicine clinic
Children's hospital
School system
Home Health Care
Physician's Office
Skilled nursing facility

ASHA Certification	Yes   No
		date (mm/yy)
CPR Certification	Yes   No
		date (mm/yy)

Comments :

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