Skills Checklist

Congratulations on your decision to apply for a Travel position with Med Travelers! Before we can offer you an employment opportunity, an electronic skills assessment must be completed. From the skills checklist below, please locate the list that matches your specialty and complete the online form. Be sure to review your information thoroughly before clicking the submit button. Thank you!

SLP/SLPA Skills Checklist

*

Denotes required field

This profile is for use by healthcare professionals in this discipline and specialty.  It will not be a determining factor for the program.
Please enter your full legal name as it appears on your Social Security Card.
First Name*	Middle Name	Last Name*
E-Mail Address*	Phone Number*

 

 

Please mark your level of experience

1. No experience; requires education, training and supervision
2. Intermittent experience; may need support or supervision
3. Proficient; consistent experience, independent
4. Expert level; can teach/supervise others

 

CLINICAL SETTING

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2

3

4

 

Acute Care - Adult

 

Acute Care - Pediatric

 

Home Health Care - Adult

 

Home Health Care - Pediatric

 

Inpatient Rehabilitation Facility

 

Long Term Acute Care (LTAC)

 

Outpatient - Adult

 

Outpatient - Pediatric

 

Psychiatric

 

School

 

Skilled Nursing Care

 

Teletherapy: (enter setting)

 

ASSESSMENT – PEDIATRIC

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2

3

4

 

Clinical Evaluation of Language Fundamentals (CELF)

 

Comprehensive Assessment of Spoken Language (CASL)

 

Goldman Fristoe Test of Articulation (GFTA)

 

Preschool Language Scale (PLS)

 

Rossetti Infant-Toddler Language Scale

 

Stuttering Severity Instrument (SSI)

 

Test of Language Development (TOLD)

 

Test of Pragmatic Language (TOPL)

 

ASSESSMENT – ADULT

1

2

3

4

 

Boston Diagnostic Aphasia Examination Experience

 

Brief Interview for Mental Status (BIMS)

 

Cognitive Performance Scale (CPS)

 

Flexible Endoscopic Evaluation of Swallowing (FEES)

 

Minnesota Test for Differential Diagnoses of Aphasia Experience

 

Modified Barium Swallow

 

National Outcomes Measurement Systems (NOMS)

 

Porch Index of Communicative Abilities Experience

 

Reading Comprehension Battery for Aphasia Experience

 

Rehab Institute of Chicago Eval. of Communication Exp.

 

Ross information Processing Assessment – Geriatric Experience

 

Western Aphasia Battery Experience

 

AREAS OF TREATMENT – PEDIATRIC

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2

3

4

 

Alternative Augmentative Communication

 

Apraxia

 

Articulation/Phonology

 

Dysphagia

 

Fluency

 

Receptive/Expressive Language

 

Voice/Resonance

 

AREAS OF TREATMENT - ADULT/GERIATRIC

1

2

3

4

 

Aphasia

 

Dysarthria

 

Dysphagia

 

Memory/Cognition

 

Receptive/Expressive Language

 

Speech Generating Device

 

Voice/Resonance

 

DOCUMENTATION SYSTEMS/METHODS

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2

3

4

 

Care Manager

 

Casamba

 

Cerner

 

Epic

 

McKesson

 

Meditech

 

Rehab Optima

 

School IEP Documentation Systems

 

BILLING DOCUMENTATION

1

2

3

4

 

ICD-10 Coding: Medical Diagnosis

 

ICD-10 Coding: Treatment Diagnosis

 

Medicaid/Medical

 

Medicare Part A

 

Medicare Part B

 

Patient Driven Payment Model (PDPM)

 

Patient Driven Groupings Model (PDGM)

 

OASIS

 

SUPERVISION

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2

3

4

 

Supervises Clinical Fellows

 

Supervises SLPA

 

Supervises Rehab Staff

 

Age Specific

1

2

3

4

 

Neonate/Infant

 

Toddler/Preschool

 

School Age Children

 

Adolescents

 

Young/Middle Adults

 

Older Adults/Geriatrics

 

CERTIFICATIONS AND QUALIFICATIONS (Current at time of completing this form)

 

Praxis Exam

Yes

No

 

CCC-SLP

Yes

No

 

Bilingual Endorsement Language:

 

Dementia Certification

Yes

No

 

Flexible Endoscopic Evaluation of Swallowing (FEES)

Yes

No

 

Lee Silverman Voice Treatment (LSVT)

Yes

No

 

Modified Barium Swallow Impairment Profile (MBSImP)

Yes

No

 

Non Violent Crisis Intervention (e.g. CPI)

Yes

No

 

CPR/BLS

Yes

No

 

Other: Specify

SLP/SLPA Skills Checklist, version 8

You must agree with the statements at the bottom of the form before submitting your skills checklist.

Please read and agree to the statements below by marking the checkbox.

* I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. Falsification of any information provided, will result in being ineligible to travel with AMN. I hereby authorize the Company to release this Skills Checklist to the Client facilities in relation to consideration of employment as a Healthcare Professional with those facilities.