SLP Clinical Experience Form
CLINICAL EXPERIENCE SUMMARY
School of Communicative Disorders
University of Wisconsin-Stevens Point
Please provide the following information concerning your clinical practicum experiences and return it with your Application for Admission into the graduate program. In addition, if you have been employed in the field of communicative disorders, please describe your job on the back of this form. Please include information such as your employer, dates of employment, types of cases serviced, and any other relevant information about your position.
(1) Have you completed 25 hours of clinical observations? Yes ____ No ____
(2) Have you earned clinical hours as an undergraduate? Yes ___ No___.
If so, please complete the blanks below with the number of hours you have earned.
Include only those hours earned under the supervision of someone holding ASHA
Certification, or its equivalent, in the appropriate area.
For those seeking CCC in Speech and Language For those seeking CCC in Audiology
A. Therapy clock hours: A. Audiology clock hours:
Adults Children Adults Children
Language ________ _______ Habilitation or
Articulation ________ _______ Rehabilitation ________ _______
Voice ________ _______ Diagnostics ________ _______
Fluency ________ _______
Hearing Impaired ________ _______ TOTALS ________ _______
TOTALS ________ _______ B. Clock Hours in
Speech/Language ______ _______
B. Diagnostic clock hours: not related to
Adults Children hearing impaired
Speech and
Language ________ _______
Hearing ________ _______
(3) How many additional hours do you expect to complete prior to entering graduate
school? _________
(4) Have you completed a student teaching assignment in a public school or equivalent
setting? ______ If not, do you plan to complete a student teaching assignment prior
to your entering graduate school? ______ If not, do you plan to do so as a part of your
graduate program? ______
(5) Are you currently certified to work as a clinician in the public schools in the State of
Wisconsin or another state? _____ If yes, what state? ________________________
If not, do you plan to become certified for public school employment? _______
______________________________________ _____________________
Your Name Date
4/24/2006