Speech Language Pathologist Skills Checklist

Name
Last 4 of SSN
Email ID
Date

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Please list any Additional Skills:
1:
2:
3:
4:

Additional training:
1:
2:
3:
4:

Additional equipment:
1:
2:
3:
4:

Upload Document / Image (Optional)

Supported extensions: .pdf, .doc, .docx, .jpg, .png (Max: 5MB)