SLP Skills Checklist

This checklist helps MAS Medical clearly outline your areas of expertise. Please complete this checklist as thoroughly as possible.

The Purpose of this checklist is to more clearly outline the Speech Therapist's areas of expertise. Please complete this checklist as thoroughly as possible.
Today's Date*
First Name*
Last Name*
Email*
Education*
Certifications/ Expirations (BCLS, ACLS, CPR etc)*
State SLP Licenses*
Please check those areas you have experience in and comment on depth and breadth of experience where necessary.

A. SPEECH/ LANGUAGE/ HEARING DISABILITIES
Autism*
No Experience Less Than One Year More Than One Year
Cleft Palate*
No Experience Less Than One Year More Than One Year
Congenital Defects*
No Experience Less Than One Year More Than One Year
Stroke*
No Experience Less Than One Year More Than One Year
Fluency*
No Experience Less Than One Year More Than One Year
Head Injuries*
No Experience Less Than One Year More Than One Year
Neurological Disorders*
No Experience Less Than One Year More Than One Year
Hearing Impaired / Deaf*
No Experience Less Than One Year More Than One Year
Voice*
No Experience Less Than One Year More Than One Year
Neurodevelopmental Disorders*
No Experience Less Than One Year More Than One Year
C. EXPERIENCE WITH AGE GROUPS
Able to adapt care to incorporate normal growth and development*
- Pediatrics
- Adole
- Adult
- Geriatrics
Able to adapt method and terminology of patient instruction to age comprehension and maturity level*
- Pediatrics
- Adole
- Adult
- Geriatrics
Able to ensure a safe environment reflecting specific needs of age group*
- Pediatrics
- Adole
- Adult
- Geriatrics
D. EXPERIENCE WITH SETTINGS
Neurodevelopmental Disorders*
No Experience Less Than One Year More Than One Year
Rehabilitation Hospital*
No Experience Less Than One Year More Than One Year
Home Health*
No Experience Less Than One Year More Than One Year
Long Term Care*
No Experience Less Than One Year More Than One Year
Nursing Home*
No Experience Less Than One Year More Than One Year
Out Patient Clinic*
No Experience Less Than One Year More Than One Year
Pediatric Rehabilitation*
No Experience Less Than One Year More Than One Year
Industrial Setting*
No Experience Less Than One Year More Than One Year
School System*
No Experience Less Than One Year More Than One Year
Confirmation*
- I attest that the information I have provided is true and accurate to the best of my knowledge
I am the individual completing this form. By checking this box I authorize MAS Medical Staffing to release this checklist to client facilities in consideration for employment.

A. SPEECH/ LANGUAGE/ HEARING DISABILITIES

C. EXPERIENCE WITH AGE GROUPS

D. EXPERIENCE WITH SETTINGS