PPR Healthcare Staffing, Inc.
333 1st. St. North -- Suite 200
Jacksonville Beach, FL 32250
Fax:(888)794-5038

Speech Language Pathology Skills
Name:   Date:  
Social Security number:   Email:  
Instructions: Use the following Answer Key to indicate the extent of your previous experience:
Key - for each box mark:   A. Theory, no practice, B. Intermittent experience,
    C. One - two years experience, D. Two plus years experience

CLINICAL SKILLS
Familiarity with standardized tests
    ALPS (Aphasia language performance scale) ABCD
    Boston ABCD
    CADL (Communication ability for daily living) ABCD
    Detroit ABCD
    Minnesota (Schuell) ABCD
    PICA (Porch index of communication ability) ABCD
    Token ABCD
    Western aphasia battery (WAB) ABCD
Informal testing - description of:
Screening
    Ability to follow directions ABCD
    Attention span ABCD
    Expressive/receptive skills ABCD
    Familiarize self with chart ABCD
    Hearing ABCD
    Memory skills ABCD
    Oral motor movement ABCD
    Talking to staff ABCD

THERAPY SKILLS/QUANTITY EXPERIENCE
Aphasia
    CVA ABCD
    Head trauma ABCD
    Low level functioning patients ABCD
Oral motor disorders
    Apraxia ABCD
    Dysarthria ABCD

NEUROLOGICAL DISORDERS
Adaptive feeding ABCD
ALS ABCD
Alzheimer's (Dementia) ABCD
Augmentative communications
    Communication boards, etc. ABCD
    Electronic devices ABCD
Aural rehabilitation
    Hearing aids ABCD
    Hearing loss ABCD
    Dysarthria ABCD
Dysphagia
    Trachs ABCD
    Ventilator dependent patients ABCD
    Videofluroscopy ABCD
Fluency ABCD
Parkinson's disease ABCD
Therapy techniques ABCD
Voice - laryngectomy ABCD
How do you feel about proceeding with therapy if you can only rely on bedside evaluation?

PEDIATRICS
Articulation ABCD
Autism ABCD
Cleft palate ABCD
Early intervention ABCD
Feeding disorders ABCD
Fluency ABCD
Hearing impaired ABCD
Traumatic brain injury ABCD

AGE SPECIFIC PRACTICE CRITERIA
Please check the boxes below for each age group for which you have expertise in providing age-appropriate care.
A. Newborn/Neonate (birth - 30 days) F. Adolescents (12 - 18 years)
B. Infant (30 days - 1 year) G. Young adults (18 - 39 years)
C. Toddler (1 - 3 years) H. Middle adults (39 - 64 years)
D. Preschooler (3 - 5 years) I. Older adults (64+)
E. School age children (5 - 12 years)

EXPERIENCE WITH AGE GROUPS:
    A B C D E F G H I
Able to adapt care to incorporate normal growth and development.  
 
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.  
 
Can ensure a safe environment reflecting specific needs of various age groups.  

Certification:
Please check the boxes below and indicate the expiration date for each certificate that you have. If you do not know the exact date, please use the last date of the specific month (e.g., 01/02/2004).
BCLS Exp. date: (mm/dd/yyyy)
ACLS Exp. date: (mm/dd/yyyy)
CPR Exp. date: (mm/dd/yyyy)
Other: Exp. date: (mm/dd/yyyy)
Computerized charting system: Exp. date: (mm/dd/yyyy)
 
The information I have given is true and accurate to the best of my knowledge. I hereby authorize PPR to release this information to Client facilities of PPR in relation to consideration of my employment with those facilities.



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