* Required Information

BASIC QUESTIONNAIRE

PROVIDER INFORMATION

CLINICAL FELLOW INFORMATION

Only applicants applying for a position as a Clinical Fellow need to complete this section.

If you answer “Yes” to any of the questions below, provide explanation on a separate page.

EDUCATION



LANGUAGE

PROFESSIONAL REFERENCES

Provide the name, relationship, address and telephone number of three professional references.



EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.



Clinical Experience and Expertise

If applying for a clinical position, indicate the ESTIMATED years of experience for each age group that corresponds to the type in the left column.

STANDARDIZED ASSESSMENTS Observed ONLY Administered Yes/No Birth – Age 3 Preschool (3-5) School Age (5-21) Adult (21-65) Geriatric (65+)
TREATMENTS Birth – Age 3 Preschool (3-5) School Age (5-21) Adult (21-65) Geriatric (65+)
  Childhood Apraxia of Speech
  Feeding/Swallowing
  Language – Expressive & Receptive
  Aphasia
  Voice
  Apraxia
  Dysarthria
  Cognitive
  Dementia
  Aural Rehabilitation
  Resonance
  Fluency
  Pragmatics
  Articulation/Phonology
  Augmentative and Alternative Communication
  Auditory Processing, discrimination, memory/cognition
SETTINGS TREATED Birth – Age 3 Preschool (3-5) School Age (5-21) Adult (21-65) Geriatric (65+)
  CDSA
  Home
  Daycare
  Office Clinic
  School – Pre-K
  School – Elementary
  School – Middle
  School – High School
  School – Charter School
  School – Private
  School – Self-Contained
  School – Head Start
  School – Inclusion Services
  Home Health Agency
  Hospital – Outpatient
  Hospital – Inpatient
  Hospital – Long Term Acute Care
  Skilled Nursing Facility
  Assisted Living Facility
  ICF-MR
  Group Home
MEDICAL DIAGNOSES TREATED Birth – Age 3 Preschool (3-5) School Age (5-21) Adult (21-65) Geriatric (65+)
  Asperger’s Syndrome
  Autism Spectrum
  Cerebral Palsy
  Cleft Palate
  Down Syndrome
  CVA/Strokes
  TBI
  Tracheostomy
  Hearing Impaired/Loss
  Cochlear Implants
  Genetic Disorders/Syndromes
  Developmental Delays
  Intellectual Disability
  Central Auditory Processing Disorder

Check or indicate any Special Clinical Certifications or Techniques

Special Skills and Qualifications

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