Department of Communication Sciences & Disorders

Student:

Supervisor:

Semester:

Date of Evaluation:

Tier One Subcategories

Score

N/A

Pre-Emergent

Emerging

Proficient

Exemplary

Interpersonal Skills (11)

Ethical Conduct (4)

Reporting (9)

Add Tier One Scores and divide by # of subcategories in which the student received a score.

Tier ONE Average:

Tier Two Skills Ratings

Score

N/A

Pre-Emergent

Emerging

Proficient

Exemplary

Assessment  (7)

Development/Planning  (5)

Teaching/Intervention (8)

Add Tier Two Scores and divide by # of subcategories in which the student received a score.

Tier TWO Average:

Add Tier One score and Tier Two Score, and  divide by TWO.

OVERALL SCORE

Key for Competency Achievement:

X  

Exemplary:  Serves as a professional and educational model; proficient for beginning Clinical Fellowship

10

P

 Proficient:  Performs the competency independently; proficient for beginning clinical fellowship

8—9

E

Emerging:  Performs the competency with support of instructor

(5=entry, 6=intermediate, 7=advanced)

5—7

U

Pre-emergent:  Competency is not evident to begin career

4 and below

N/A

Not applicable

-----------------------

Student:

Supervisor:

Semester:

Site:

Program: Graduate_____   Undergrad_____

Experience Level:

Type of Evaluation: Midterm or Final:

Date of Evaluation:

Grade:

Artic/Phono

Fluency

Voice/Res      

Rec/Exp Lang    

Hearing 

Swallowing

Cog Aspects    

Soc Aspects    

Comm Mod

Clinical Instructor’s Name (please print)

Clinical Instructor’s Signature

Clinical Instructor’s ASHA Certification Number

Student:

Supervisor:

Semester:

Date of Evaluaton:

PROFESSIONAL/INTERPERSONAL SKILLS  (Tier 1)

(11 items possible)

Add total score:                          ________

Divide by # of items scored=     ________

Does

not

apply

Specific direction from supervisor does not alter unsatisfactory performance & ability to make changes

Needs specific direction and/or demonstration from supervisor to perform effectively

Needs general direction from supervisor to perform effectively

Demonstrates

independence by

taking initiative; makes changes when appropriate; & is effective

1.

Shows understanding of client’s problems, needs, stresses. 

0

1

2     3     4

5     6     7

8     9    10

2.

Communicates effectively. Recognizes needs, values, preferred mode of communication & cultural/linguistic background of client & relevant others. IV.G.3.a 

0

1

2     3     4

5     6     7

8     9     10

3.

Perceives verbal & nonverbal cues that client isn’t understanding or unable to do all or part of tasks.

0

1

2     3     4

5     6     7

8     9     10

4.

Conveys to client & relevant others expectations of behavior & performance.

0

1

2     3     4

5     6     7

8     9     10

5.

Interaction with supervisor in therapy and/or client related discussions is appropriate & respectful.

0

1

2     3     4

5     6     7

8     9     10

6.

Collaborates with other professionals in case management as appropriate.IV.G.3.b

0

1

2     3     4

5     6     7

8     9     10

7.

Is punctual for client and supervisor appointments and cancels appointments in a timely manner as needed.

0

1

2     3     4

5     6     7

8     9     10

8.

Follows dress code and conduct code of site.

0

1

2     3     4

5     6     7

8     9     10

9.

Respects the privacy of daily clinical operations pertaining to caseload (conversations, files, computer documentation, email, etc)

0

1

2     3     4

5     6     7

8     9     10

10.

Completes duties as asigned and demonstrates a willingness to help as needed for the success of the organization (teamwork).

0

1

2     3     4

5     6     7

8     9     10

11.

Demonstrates ability to judge own performance, determine areas for growth, set professional development goals, and judge progress to achieving those goals.

0

1

2     3     4

5     6     7

8     9     10

ETHICAL CONDUCT (Tier 1)

(4 items possible)

Add total score:                          ________

Divide by # of items scored=     ________

Does

not

apply

Specific direction from supervisor does not alter unsatisfactory performance & ability to make changes

Needs specific direction and/or demonstration from supervisor to perform effectively

Needs general direction from supervisor to perform effectively

Demonstrates

independence by

taking initiative; makes changes when appropriate; & is effective

1.

Adheres to ASHA Code of Ethics & behaves professionally. IV.G.3.d  Principle I
Individuals shall honor their responsiblitiy to hold paramount the welfare of persons they serve professionally or participants in research and scholarly activities and shall treat animals involved in research in a humane manner. à

      0

                 1

           2      3     4

          5     6     7

         8     9     10

e.g.,  provide services competently, use every resource, including referral, not discriminate; not misrepresent credentials; full disclosure/informed consent; evaluates effectiveness of services; does not guarantee results; does not provide treatment solely by correspondence; maintains and appropriately secures records; does not charge for service not rendered; seeks help if ability to provide services is adversely affected by a health-related condition.

2.

Adheres to ASHA Code of Ethics & behaves professionally. IV.G.3.d Principle II

Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence.  à

      0

                 1

           2      3     4

          5     6     7

         8     9     10

e.g., provide services only when supervised by individual who holds CCCs;  practice within the scope of competence; continue professional development, including attendance and participation in practicum class; ensure all equipment used in service is properly working and calibrated as necessary.

3.

Adheres to ASHA Code of Ethics & behaves professionally. IV.G.3.d  Principle III

Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions, including dissemination of research findings and scholarly activities.  à

      0

                 1

           2      3     4

          5     6     7

         8     9     10

e.g., promotes public understanding of persons with communication disorders and services available; supports development of services to address unmet public need; provides accurate information in all communications regarding the professions.

4.

Adheres to ASHA Code of Ethics & behaves professionally. IV.G.3.d  Principle IV

Individuals shall honor their responsibilities to the professions and their relationships with colleagues, students, and members of allied professions.  Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious inter-professional relationships, and accept the professions’ self-imposed standards.  à

      0

                 1

           2      3     4

          5     6     7

         8     9     10

e.g., shall not engage in conduct that adversely reflects on professions or individual’s fitness to serve persons professionally; shall not engage in sex with clients or students over whom they exercise authority; shall reference the source and assign credit only to those who contributed to a publication, presentation, or product; shall not misrepresent statements; shall not provide professional services without exercising independent professional judgment; shall not discriminate in relationships.

REPORTING/COMMUNICATION (Tier 1)

(9 items possible)

Add total score:                          ________

Divide by # of items scored:      ________

Does

not

apply

Specific direction from supervisor does not alter unsatisfactory performance & ability to make changes

Needs specific direction and/or demonstration from supervisor to perform effectively

Needs general direction from supervisor to perform effectively

Demonstrates

independence by

taking initiative; makes changes when appropriate; & is effective

1.

Report information is pertinent, accurate and supports intervention and evaluation.

0

1

2     3     4

5     6     7

8     9    10

2.

Written communication is concise.

0

1

2     3     4

5     6     7

8     9    10

3.

Completes administrative functions necessary to support assessment &/or intervention. IV.G.1.f; IV.G.2.f

0

1

2     3     4

5     6     7

8     9     10

4.

Uses appropriate mechanical writing skills (spelling, grammar, organization, etc.).

      0

                 1

           2      3     4

          5     6     7

         8     9     10

5.

Uses professional terminology appropriately.

      0

                 1

           2      3     4

          5     6     7

         8     9     10

6.

Observes time lines to submit lesson plans, drafts and reports.

      0

                 1

           2      3     4

          5     6     7

         8     9     10

7.

Keeps accurate and current clock hours and submits them for supervisor approval in timely manner.

8.

Possesses skill in oral or other forms of communication sufficient for entry into professional practice. IV.B.

(e.g., use of professional voice, pragmatics)

0

1

2     3     4

5     6     7

8     9     10

9.

Possesses skill in written forms of communication sufficient for entry into professional practice. IV.B.  (e.g.,  handouts, emails, letters)

0

1

2     3     4

5     6     7

8     9     10

ASSESSMENT (Tier 2)

ASSESSMENT includes:

Screening

Diagnostic evaluations

Baseline  assessments at the beginning of a treatment period

Re-assessment

(7 items possible)

Add total score:                          ________

Divide by # of items scored=     ________

Does

not

apply

Specific direction from supervisor does not alter unsatisfactory performance & ability to make changes

Needs specific direction and/or demonstration from supervisor to perform effectively

Needs general direction from supervisor to perform effectively

Demonstrates

independence by

taking initiative; makes changes when appropriate; & is effective

1.

Conducts screening procedures. IV.G.1.a

(e.g., hearing screening, communication development screening, swallow screening)

0

1

2     3     4

5     6     7

8     9    10

2.

Collects or becomes familiar with case history information and information from relevant others and other professionals. IV.G.1.b

(e.g., preparation for diagnostic evaluation; preparation for initial baseline session with new client)

0

1

2     3     4

5     6     7

8     9     10

3.

Selects and administers appropriate evaluation procedures such as behavioral observations, non-standardized and standardized test and instrumental procedures. IV.G.1.c

(e.g., planning and administering assessment to gather baseline performance at the beginning of a treatment period; planning and carrying out  a diagnostic evaluation; re-assessment after a period of treatment or a break from treatment)

0

1

2     3     4

5     6     7

8     9     10

4.

Adapts evaluation procedures to meet client needs. IV.G.1.d

(applies to any assessment type)

0

1

2     3     4

5     6     7

8     9     10

5.

Scores, interprets, integrates and synthesizes all information to develop diagnoses and make appropriate recommendations for intervention.

IV.G.1.e

(e.g., diagnostic assessment; gathering of accurate baseline data, re-assessment throughout episode of care)

0

1

2     3     4

5     6     7

8     9     10

6.

Refers for appropriate services as needed. IV.G.1.g

(May occur as part of an initial assessment or at any time during a course of treatment, as the intern is expected to assess client status throughout the course of care)

0

1

2     3     4

5     6     7

8     9     10

7.

Measures and evaluates client performance and progress throughout assessment and intervention. IV.G.2.d

(May occur as part of an initial assessment or at any time during a course of treatment, as the intern is expected to assess client status throughout the course of care)

0

1

2     3     4

5     6     7

8     9     10

DEVELOPING AND PLANNING (Tier 2)

(5 items possible)

Add total score:                          ________

Divide by # of items scored=     ________

Does

not

apply

Specific direction from supervisor does not alter unsatisfactory performance & ability to make changes

Needs specific direction and/or demonstration from supervisor to perform effectively

Needs general

direction from supervisor to perform effectively

Demonstrates

independence by

taking initiative; makes changes when appropriate; & is effective

1.

Develops appropriate intervention goals, with measurable and achievable objectives that meet client needs, based on academic knowledge, assessment, research, supplemental reading and observations of clients with similar needs. IV.G.2.a

0

1

2     3     4

5     6     7

8     9    10

2

Develops appropriate intervention goals, with measurable and achievable objectives that meet client needs and demonstrate consideration of client’s social/cultural values.

3.

Collaborates with others in the planning process as appropriate. IV.G.2.a

4.

Plans and sequences appropriate strategies, stimulus materials or instrumentation that meet age and ability level of client.

0

1

2     3     4

5     6     7

8     9     10

5.

Modifies intervention plans, strategies, materials or instrumentation as appropriate to meet the need of the client.IV.G.2.e

0

1

2     3     4

5     6     7

8     9     10

TEACHING AND INTERVENTION (Tier 2)

(8 items possible)

Add total score:                          ________

Divide by # of items scored=     ________

Does

not

apply

Specific direction from supervisor does not alter unsatisfactory performance & ability to make changes

Needs specific direction and/or demonstration from supervisor to perform effectively

Needs general direction from supervisor to perform effectively

Demonstrates

independence by

taking initiative; makes changes when appropriate; & is effective

1.

Gives clear, concise instructions in intervention and assessment, modifying language to meet needs of client and relevant others.

0

1

2     3     4

5     6     7

8     9    10

2.

Conducts prevention procedures and activities.IV.G.1.a

0

1

2     3     4

5     6     7

8     9     10

3.

Implements intervention plan utilizing planned procedures, and involves relevant others in the process. IV.G.2.b

0

1

2     3     4

5     6     7

8     9     10

4.

Selects or develops and uses appropriate materials and instrumentation for prevention and intervention. IV.G.2.c

0

1

2     3     4

5     6     7

8     9     10

5.

Monitors client progress with accurate data collection.

0

1

2     3     4

5     6     7

8     9     10

6.

Is able to modify treatment plan when client is not understanding/performing a task in therapy session.

0

1

2     3     4

5     6     7

8     9     10

7.

Is able to recognize mistakes made in therapy session and generate ideas to improve the situation.

0

1

2    3     4

5     6     7

8     9     10

8.

Provides counseling regarding communication and swallowing disorders to clients and relevant others. IV.G.3.c

0

1

2     3     4

5     6     7

8     9     10