Department of Disorders and Sciences Evaluation of Speech-Language Pathology Student Extern Midterm Assessment Final Assessment Student: Supervisor(s): Midterm Evaluation Period: From: To: Final Evaluation Period: From: To: Facility: Date of Evaluation: Facility Address: Supervisor Signature: ASHA Number: Signature of Student: Please Note: This grading system assumes that students new to a clinical setting and/or type of disorder will require more guidance and supervision at the beginning of the externship. They are expected to move toward increasing proficiency and independence as the externship progresses, and therefore need less supervision. Please keep in mind that ASHA requires that at least 25 percent of treatment sessions are observed by an externship supervisor. Rating Scale for Student Evaluation: 0 Not applicable to this setting or this student 1 100% direct supervision is required* 2 75% direct supervision is required* 3 50% direct supervision is required* 4 25% direct supervision is required* 5 The student demonstrates the ability to work without supervision in this area. *Direct supervision is defined as a supervisor assuming a dominant role in diagnostic evaluations and therapy management by providing input on diagnostic interpretation, goal formulation, perception of strengths and weaknesses. The supervisor will also be demonstrating techniques prior to implementation.
SECTION I During his/her externship, the student experienced the following cases, diagnoses, assessments, interventions, and conceptual information (Please check): Articulation Fluency Voice & Resonance Receptive & Expressive Language Hearing Swallowing Cognitive Aspects of Social Aspects of Modalities Adults Peds SECTION II The competencies evaluated in this section are largely demonstrated outside of the therapy room, and relate to the development and planning of goals, analysis of sessions, documentation of client/ patient behaviors, and communication with staff. You should evaluate the student s performance using the dependenceindependence rating scale, as described on page 1. 1. Ability to extract and interpret case history information from the clients charts or records (section IB from 2. Ability to choose appropriate diagnostic instruments (section IC from 3. Ability to interpret test results accurately; translates information into a diagnostic statement (section IE from 4. Ability to develop appropriate long-term goals (sections IE and IIA from 5. Ability to write goals which are precisely defined, clearly stated, and related to specific objectives (section IIA from 6. Ability to plan activities for therapy sessions which are clearly related to stated goals (section IIC from 7. Ability to devise and/or adapt procedures and materials for the specific needs of the client (section ID from 8. Ability to plan sessions which are realistic in terms of stated goals, clients behavior, and time limitations (section IIC from 9. Ability to accurately and constructively analyze sessions and use the analysis as a basis for planning subsequent sessions (section IID from 10. Ability to analyze own clinical behavior with respect to impact on clients behavior 11. Ability to accurately collect data and document progress in a timely manner (sections IE and IF from 12. Ability to write in a concise, grammatically correct manner (section IF from 13. Adhere to the ASHA Code of Ethics and behave professionally (section IIID from Dependent Independent Dependent Independent
SECTION III The competencies evaluated in this section relate to the student s direct contact with clients/ patients, performance in therapy sessions and counseling. Evaluate the student on the dependence independence rating scale, as described on page 1. 1. Ability to administer formal tests according to published guidelines (section IC from 2. Ability to administer an informal diagnostic assessment when commercially available tests are not appropriate (section ID from 3. Ability to establish rapport with clients, leading to an effective therapeutic relationship (sections IIIA and IIIC from 4. Ability to perceive and interpret clients verbal and nonverbal behaviors relating to motivation and therapeutic interaction (sections IE, IID, IIIA, and IIIC from 5. Ability to select and use appropriate cueing and prompting to reinforce desired behaviors and responses to achieve the target outcomes for effective intervention (sections IIC, IIE from 6. Ability to increase or decrease difficulty of tasks within a session, when indicated (section IIE from 7. Ability to give clear, precise instructions when presenting procedures and materials (sections IIB, IIC, IIA and IIIC from 8. Ability to modify complexity of language to meet clients needs (sections IIE, IIA, and IIIC from 9. Ability to quickly, skillfully, and effectively set limits in a nonthreatening manner when necessary; manage client behavior effectively (section IIE from 10. Ability to work effectively to increase client s level of motivation (section IIE from 11. Ability to recognize and utilize unexpected opportunities to achieve stated therapy goals 12. Refer clients for appropriate services (sections IG and IIG from 13. Ability to convey information to parents, other family members or caregivers regarding their role in facilitating carryover and/or generalization outside the therapy session (sections IG, IIG, IIA, IIB, and IIIC from 14. Ability to modify complexity of technical information to effectively communicate with adult clients, parents of child clients, or other family members or caregivers, regarding therapy goals, progress, and prognosis (sections IIA and IIC from 15. Adheres to ASHA Code of Ethics and behaves professionally (section IIID from Dependent Independent Dependent Independent
SECTION IV Clinician comportment is evaluated in this section and relates to the student s personal manner, bearing, and behavior towards his/her superiors, colleagues, and clients. Appearance in terms for appropriate workplace attire is also rated. You should evaluate the student s performance using the dependence independence rating scale as described on page 1. 1. Demonstrates respect for and deference to supervisors, managers, nurses, and/or physicians. 2. Demonstrates respect and consideration for client and client s family. 3. Demonstrates a professional demeanor with colleagues and co-workers. 4. Demonstrates a professional demeanor with client and client s family. Dependent Independent Dependent Independent 5. Arrives and departs on time. 6. Provides ample notice when requesting time off and/or potential schedule conflicts. 7. Takes breaks as directed and returns to position at appointed time. 8. Maintains an appropriate workplace appearance and abides by workplace dress codes. 9. Works within boundaries set by supervisor and/or management and adheres to chain of command for problems and decision making. 10. Demonstrates an accepting manner when receiving constructive critique and suggestions. 11. Demonstrates willingness to consider and/or implement suggestions offered by supervisor. 12. Demonstrates willingness to collaborate with colleagues, coworkers and other disciplines. GENERAL COMMENTS (see next page also):
Student Level at Beginning of Externship: (Insert comments about student readiness here) Clinical Instruction Plan Mid-Semester Evaluation: (Insert comments about student progress here) (List 3 7 competencies to be targeted in 2 nd half of externship: write in specific information concerning behaviors, skills, or attitudes to be developed.) Supervisor s Signature: EVALUATION (Summarize progress and write recommendations for future clinical experiences) Date: Supervisor s Signature: Date: Grade Recommendation: Credit / No Credit (Please circle one) Thank You!