Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
FLUENCY - Voice
Videostroboscopy 0 1 2
Visipitch 0 1 2
LSVT 0 1 2
AURAL REHABILITATION
Sign Language 0 1 2
Audiometric screenings 0 1 2
Cued speedy 0 1 2
Speech reading 0 1 2
CLEFT PALATE
Prosthetic devices 0 1 2
Palatal lifts 0 1 2
Obturators 0 1 2
Feeding disorders 0 1 2
AUGMENTATIVE COMMUNICATION
Computer applications 0 1 2
Communication board 0 1 2
DYSPHAGIA
Videofluoroscopy/MBS 0 1 2
Ultrasound 0 1 2
Cervical Auscultation 0 1 2
SEMG-Surface Electro Myography
(Biofeedback) 0 1 2
Adaptive Equipment 0 1 2
F.E.E.S. 0 1 2
Bedside Exams 0 1 2
Thermo Stim 0 1 2
DPNS (Deep Pharyngeal Nuero Stim) 0 1 2
Electrical stimulation 0 1 2
Diet Classifications 0 1 2
PT/Caregiver Training & Instruction 0 1 2
NEUROGENIC
CVA 0 1 2
Aphasia 0 1 2
Traumatic Brain Injury
Cognitive rehab 0 1 2
Coma stimulation 0 1 2
Rancho Levels 0 1 2
Craniotomy 0 1 2
Motor Speech Disorders
Dysarthria 0 1 2
Apraxia 0 1 2
E-Stim 0 1 2
PROGRESSIVE DISORDERS
ALS 0 1 2
MS 0 1 2
Parkinson’s 0 1 2
Huntington’s 0 1 2
Guillian-Barre’ 0 1 2
VENTS/TRACHS
Trach management 0 1 2
Ventilator Interpretation 0 1 2
Passy Muir valves 0 1 2
Pulse Oximetry 0 1 2
MEDICAL
Suctioning 0 1 2
Head & Neck Cancers 0 1 2
Trauma 0 1 2
Vital Signs 0 1 2
LARYNGECTOMEE
Electro Larynx 0 1 2
Esophageal Speech 0 1 2
PEDIATRICS
Autism 0 1 2
Developmental Delays 0 1 2
Phonologial Processes 0 1 2
Articulation 0 1 2
Phonetic Transcription 0 1 2
Dysphasia 0 1 2
Language Stimuation 0 1 2
Feeding Disorders 0 1 2
Cerebal Palsy 0 1 2
Genetic Syndromes 0 1 2
Oral/Motor 0 1 2
Early Intervention Evaluations 0 1 2
Sensory Integration 0 1 2
DEMETIA MANAGEMENT
Dysphasia Dining 0 1 2
Memory Book 0 1 2
EDUCATION
In-services/Education 0 1 2
Special Education 0 1 2
IEP (Individual Education Plan) 0 1 2
DOCUMENTATION
Care Planning Meetings 0 1 2
700 & 701 Forms 0 1 2
MDS Forms 0 1 2
PPS Forms 0 1 2
FIM Scores 0 1 2
(Functional Independence Measures)
NOMS 0 1 2
(National Outcomes Measurement System)
SOAP Notes 0 1 2
(Subjective, Objective, Assessment Plan)
Chart Review 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(Birth - 1 Year) B= Pediatric/Adolescent(1-18 Yrs) C=Adultt(19-64 Yrs) D=Geriatric(65 + Yrs)
A
B
C
D
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.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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