CYNET_SYSTEMS_MAIN_LOGO.gif   AUDIOLOGIST SKILLS CHECKLIST
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group 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

  
       
Rating Stars (Click) PATIENT INTERVIEW/AUDIOLOGIC CASE HISTORY 1 2 3 4  
Exhibits professional behavior during interactions  
Asks appropriate questions  
Asks appropriate follow-up questions  
Uses both open and closed questions  
Puts the patient at ease  
Facilitates a professional atmosphere  
Rating Stars (Click) OTOSCOPY 1 2 3 4  
Makes appropriate referrals  
Uses accurate and professional description of findings  
Uses appropriate skill technique  
Demonstrates knowledge and use of equipment  
Rating Stars (Click) IMMITTANCE TESTING 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly demonstrates acoustic reflex decay technique  
Thoroughly sets up and operates equipment   
Thoroughly demonstrates acoustic reflex threshold technique  
Exhibits an understanding and significance of test results for both pediatric and adult populations  
Accurately records results  
Thoroughly demonstrates tympanometry technique  
Rating Stars (Click) SPEECH RECEPTION THRESHOLD TESTING 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly sets up equipment and operates VU meter control for MLV and use of recorded speech  
Demonstrates SRT technique to obtain valid thresholds  
Appropriately demonstrates masking technique for SRT  
Rating Stars (Click) PURE-TONE TESTING BY AIR CONDUCTION 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly sets up and operates equipment  
Thoroughly demonstrates pure-tone sequence and threshold technique  
Accurate records results  
Manages difficult-to-test patients: false-positives, false negative; pediatrics; non-organic hearing loss  
Demonstrates appropriate/accurate masking technique  
Rating Stars (Click) PURE-TONE TESTING BY BONE CONDUCTION 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly sets up and operates equipment  
Demonstrates bone oscillator placement/masking transducer placement  
Exhibits sequence and technique  
Accurately records results  
Demonstrates appropriate/accurate masking technique  
Rating Stars (Click) WORD-RECOGNITION TESTING 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly sets up equipment and operates VU meter control for MLV and use of recorded speech  
Exhibits presentation level with rationale  
Accurately records results  
Demonstrates appropriate/accurate masking technique  
Rating Stars (Click) INTERPRETATION AND COUNSELING 1 2 3 4  
Appropriately describes audiogram, hearing loss severity, speech findings, and acoustic
immittance testing 		 
Integrates data for differential diagnosis  
Demonstrates knowledge of and implements aural rehabilitation  
Provides general patient counseling skills  
Provides educational counseling  
Gives appropriate recommendations  
Provides family counseling skills  
Rating Stars (Click) EAR IMPRESSIONS 1 2 3 4  
Prepares patient with appropriate instructions  
Demonstrates bracing technique  
Exhibits otoblock placement depth  
Demonstrates impression removal  
Provides overall quality of impression  
Demonstrates otoscopic re-examination  
Rating Stars (Click) OTOACOUSTIC EMISSIONS TESTING 1 2 3 4  
Shows knowledge of TEOAE and DPOAE  
Prepares patient with appropriate instructions  
Demonstrates testing technique (probe insertion)  
Shows ability to interpret/integrate results  
Rating Stars (Click) NEURODIAGNOSTIC ABR 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly sets up and operates equipment  
Demonstrates knowledge of equipment parameters  
Identifies waveforms  
Exhibits knowledge of waveform morphology  
Exhibits knowledge of normative data (latencies etc.  
Exhibits knowledge of various electrode montages  
Rating Stars (Click) TONE BURST THRESHOLD SEARCH ABR 1 2 3 4  
Prepares patient with appropriate instructions  
Thoroughly sets up and operates equipment  
Demonstrates knowledge of equipment parameters  
Exhibits knowledge of waveform morphology  
Exhibits knowledge of normative data (latencies etc.)  
Exhibits knowledge of various electrode montages  
Identifies waveforms  
Rating Stars (Click) VESTIBULAR ASSESSMENT—BASIC 1 2 3 4  
Evaluates vestibular case history  
Asks appropriate questions  
Asks appropriate follow-up questions  
Uses both open and closed questions  
Rating Stars (Click) ENG/VNG 1 2 3 4  
Prepares patient with appropriate instructions  
Determines if use of pharmacologic agents will affect outcome  
Thoroughly sets up and operates equipment  
Administers each test in battery  
Accurately administers water caloric  
Accurately administers air caloric  
Accurately interprets results  
Makes appropriate referrals and recommendations  
Rating Stars (Click) VESTIBULAR REHABILITATION THERAPY 1 2 3 4  
Patient preparation and instructions  
Appropriate determination of VRT procedures  
Correctly performs canalith repositioning manuever  
Rating Stars (Click) CERUMEN MANAGEMENT 1 2 3 4  
Prepares patient with appropriate instructions  
Determines appropriate instrument for cerumen removal  
Demonstrates CM technique—lavage  
Demonstrates CM technique—curette  
Demonstrates CM technique—suction  
Exhibits the ability to perform skill with minimal patient discomfort  
Rating Stars (Click) HEARING AID EVALUATION 1 2 3 4  
Appropriately selects test battery to support HA selection process (MCL, LDL, COSI, HHHI, lifestyle assessments, QuickSIN, TEN test, etc.  
Accurately performs test battery  
Counsels patient successfully on hearing aid choices  
Demonstrates knowledge of hearing aid technology  
Selects appropriate technology based on test performance and patient needs  
Rating Stars (Click) HEARING AID FITTING 1 2 3 4  
Exhibits ability to insert earmold/device into ear  
Accurately trims earmold tubing length  
Exhibits ability to determine appropriateness of fit (likeliness of discomfort, feedback, etc.)  
Instructs patient on care and use according to patient's level of understanding  
Rating Stars (Click) HEARING AID PROGRAMMING 1 2 3 4  
Prepares patient with accurate device and programming software setup   
Successfully manipulates program software to support optimized performance of devices (able to
change output, compressions settings, feedback and program management, etc.)
  
Rating Stars (Click) HEARING AID VERIFICATION 1 2 3 4  
Sets up and performs functional gain measurement  
Sets up and performs probe-microphone measurement  
Sets up and performs RECD protocols  
Recognizes changes required based on verification outcome  
Rating Stars (Click) HEARING AID TROUBLESHOOTING/REPAIRS 1 2 3 4  
Systematically evaluates device performance to determine cause of malfunction  
Performs electroacoustic analysis in determining device function  
Successfully performs in-office repair (tube/filter change, receiver/microphone cleaning, etc.  
Determines need for manufacturer repair  
Rating Stars (Click) SPECIALTY TESTING 1 2 3 4  
Eelectroacoustic analysis in determining device function  
Tone decay  
Lombard voice-reflex test  
Conditioned play audiometry  
Visual reinforcement audiometry  
Behavioral observation audiometry  
Tuning fork tests  
Rating Stars (Click) APD TESTING 1 2 3 4  
Obtains case history  
Selects appropriate AP tests and administers AP test battery  
Accurately analyzes and interprets AP test results  
Makes appropriate referrals and recommendations for therapy  
Rating Stars (Click) PROFESSIONALISM 1 2 3 4  
Demonstrates overall professional demeanor  
Rating Stars (Click) RECORD KEEPING 1 2 3 4  
Completes appropriate report of basic auditory assessment  
Completes appropriate report of basic vestibular assessment  
Completes appropriate ABR report  
Provides professional report of advanced studies  
Rating Stars (Click) TERTIARY SKILLS 1 2 3 4  
Exhibits rotary chair skills  
Exhibits CDP skills  
Exhibits CDVA skills  
Exhibits MLR/P300/ BioMark skills  
Exhibits ASSR skills  
Exhibits ECOCHG skills  
Exhibits VEMP skills  
Exhibits intra-operative monitoring skills  
Rating Stars (Click) TINNITUS 1 2 3 4  
Obtains case history and complete tinnitus questionnaire  
Administers tinnitus evaluation  
Makes appropriate referrals and recommendations for treatment  
Dispenses devices when appropriate  
Rating Stars (Click) EMR: 1 2 3 4  
Allscripts  
Epic  
Meditech  
McKesson  
Homecare Home base  
Cerner  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) AGE APPROPRIATE CARE 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)