* Please note that fields marked with a * are required.
Date
* Applicant's Name: Last
* First
Middle Initial
* AASHA ID #
* Date CFY year completed
Please Mark Your Level of Experience 1 - No Experience 2 - Limited Experience (Assistance Needed) 3 - Some Experience (Needs Resource for Backup) 4 - Very Experienced (Requires No Supervision)
Work Settings
1
2
3
4
Acute Care
Community Re-Entry
Home Health
Outpatient Clinic
Pediatric Rehab
Psychiatric
Rehab Hospital
Rehab Unit in Hospital
School System
Skilled Nursing Facility
Adaptive Equipment
Assessment
Augmentative Communication
Computer-Based Treatment/Adaptive Microswitches
Speech/Language/Hearing Disabilities
Cleft Palate
Cognitive Rehab
Coma Stimulation
CVA/Stroke Rehab
Dysphagia
Fluency / Stuttering
Head Injury
Hearing Impaired
Laryngoctomy
Neurological
Voice
Pediatrics
Cerebral Palsy
Early Intervention
Learning Language Disabilities
Mental Retardation
NDT for Speech
Other Skills
Accent Reduction
Aural Rehabilitation / Speech Reading
Biofeedback - EMG
Cognitive Assessment
Co-Treatment with Occupational Therapy
Co-Treatment with Physical Therapy
Family Education
Group Education
Inservice Education
Myofunctional Therapy
Prosthetics - Cleft Palate
Rehab Feeding Group
Sign Language
Tracheostomy
Ventilator
Videofluroscopy
FEEST
Other Skills / Credentials Please list any aditional experience or skills that have not been included above:
* Signature (Please Type Full Name)
* Date
