Speech-Language Pathology Clinical Fellowship (Slpcf) Report And Rating Form

SPEECH-LANGUAGE PATHOLOGY CLINICAL FELLOWSHIP (SLPCF) REPORT AND RATING FORM

INSTRUCTIONS:

►An application for Membership and Certification must be submitted at this time if you have not already done so.

►A separate SLPCF Report and Rating Form must be submitted for each change in mentor, location, or regularly scheduled hours worked per week.

►All blanks and boxes must be filled in. Incomplete Report & Rating forms will be returned and will delay the processing of your application.

►A full-time SLPCF consists of a minimum of 35 hours worked per week and equals 1,260 hours throughout the 36-week SLPCF. The SLPCF

must consist of at least 36 mentoring activities, including 18 hours of on-site direct client contact observations and 18 other monitoring activities.

►Professional experience of less than 5 hours per week cannot be used to meet the SLPCF requirement.

►Use black ink only when completing this form. Print all information clearly.

Section 1. Speech-Language Pathology Clinical Fellow Information

Name ______________________________________________________________________________________

_______________________

Last

First

Middle

Maiden/Former

Home Address ____________________________________________________________________________________________________________

Street

City

State

Zip Code

Home Phone Number (_____)___________________________________

Social Security Number _____

-_____-_______

I understand that it is my responsibility to verify my SLPCF Mentor holds and maintains current ASHA certification in speech-language

pathology throughout the CF experience in order for the experience to be accepted as meeting standards.

_______________________________________________________

_________________________

______________________________

Signature of SLP Clinical Fellow

Date

ASHA Account #

Section 2. SLPCF Mentor Information

Name ________________________________________________________

Mentor’s ASHA Account Number _________________________

I verify that I hold current ASHA certification in speech-language pathology and understand that I must maintain this certification

throughout the SLPCF experience in order for the experience to be accepted as meeting standards.

__________________________________________________________________________

___________________

Signature of SLPCF Mentor

Date

Section 3. SLPCF Setting Information

Facility Name _________________________________________________________

Phone Number (______)___________________________

Address __________________________________________________________________________________________________________________________

Street

City

State

Zip Code

Section 4. SLPCF Duration (beginning and ending dates)

►The beginning date of this SLPCF is _______/________/_____

The ending date of this SLPCF is _____/_______/_________

►Total number of weeks for this SLPCF ___________

Section 5. SLPCF Activity Information (How many hours per week did you work in direct clinical contact?)

►At least 80% of the SLPCF work week must be in direct clinical contact (assessment/diagnosis/evaluation, screening, treatment, report writing,

family/client consultation, and/or counseling) related to the management process of individuals who exhibit communication difficulties.

►Do not include travel or lunch hours.

►Do not enter percentages or ranges of time.

►If the number of hours you work per week varies, you may estimate the number of hours you work in a typical week. Work weeks that consist of less

than 5 hours cannot be counted towards the clinical fellowship experience.

►Indicate the number of hours per week you spent in each of the following activities:

_________

Assessment/diagnosis/evaluation

_________

Screening

_________

Treatment (direct and indirect services)

_________

Activities related to client management (report writing, family/client consultation, and/or counseling, etc.)

_________

Other (includes in-service training and presentations)

_________

Total hours per week

AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION

Revised 6/2011

2200 Research Boulevard #313, Rockville, Maryland 20850

Speech-Language Pathology Clinical Fellowship (Slpcf) Report And Rating Form - 2011

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