CLINIC HANDBOOK

NORTHEASTERN STATE UNIVERSITY

SPEECH-LANGUAGE-HEARING CLINIC

Revised as of 6/3/19

Master of Science Program College of Science and Health Profession

Program Accredited by:

The Council on Academic Accreditation American Speech-Language-Hearing Association

10801 Rockville Pike Rockville, Maryland, 20852 Telephone: (310) 897-5700

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Clinic Faculty and Staff

Instructor/Supervisor/Program Chair: Brooke Klintworth, M.A.,

CCC-SLP Office 150, ext 3778

Assistant Professor: Dr. Janette Quarles, PhD., CCC-SLP Clinic Director/Instructor: Marcus Anderson, M.Ed., CCC-SLP Asst. Clinic Director/Instructor: Deborah Al-Rawi, M.S.,

CCC-SLP Instructor/Supervisor: Tina Linn, M.S., CCC-SLP

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Table of Contents

Section 1: Beginning of Semester Pages Clinic Faculty and Staff 2 Handbook 4-69 CALIPSO 70-75 Basic Competencies Checklist 76-87 Section 2: Clinic Forms Clinical Practicum Record 88 End of Semester Referral Form 89 Evaluation Plan 90-91 Video Assessment Clinical Practicum 92-93 Section 3: Practicum Clinical Practicum Sites 94 Internship/Externship Requirements 95 Internship/Externship Sites 96-102 Section 4: Clinic Documentation Templates Daily Lesson Plan 103 Semester Treatment Plan 104-105 Case Note 106 Diagnostic Report 107-109 Progress Report 110-115 Attendance Record 116 Case Notes Sheet 117 Record of Parent Contact 118 Record of Access to Educational Records 119 Clinic Admission Consents 120-122 Clinic Folder Checklist 123

INTRODUCTION

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This manual outlines and clarifies the policies, procedures, forms, and materials used in the Northeastern State University Speech-Language-Hearing Clinic. It provides information that will guide the student clinician and answer many of the clinical procedural questions one may have. The faculty is available for clarification as needed on any aspect of the clinic, its operation and clinician participation.

FACILITIES

We maintain clinics on all three NSU campuses. The Tahlequah clinic is located in the Cappi Wadley Reading Clinic in Bagley Hall, Third Floor. The Scottish Rite Masons Clinic on the Broken Arrow Campus is located in the Liberal Arts building in Room 170-184. THe Muskogee Clinic is housed on the 2nd floor of the Administration building.

THE SUPERVISOR

The clinical supervisor is directly responsible to the client, the student clinician and to the training program. The supervisors will hold current American Speech-Language-Hearing Association licenses and Oklahoma State licenses. The supervisor must be clinically competent and skillful in diagnostic and therapeutic performance, as it is partly through observation of the supervisor’s performance that the student clinician develops his or her own clinical skill. The supervisor who possesses clinical competence and is familiar with communication problems which are common to the hospital, community and educational settings will be able to prepare the student clinician to meet the many demands that may be made of her.

STUDENT CLINICIANS The clinic practicum is an integral part of the experience for beginning speech-language pathologists. The NSU Speech-Language Pathology Graduate Program is accredited by The Council on Academic Accreditation of the American Speech-Language-Hearing Association. The procedures in this manual ensure compliance of the site, faculty and student clinicians with this accreditation. Since the NSU SLP Program is accredited, students completing this program are eligible to apply for the ASHA Certification of Clinical

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Competence upon satisfactory completion of their Master’s degree, passing score on the Praxis test and completed application with payment of dues and/or certification fees. Upon completion of this program, students will also have the academic and clinical practicum requirements for certification as a Speech-Language Pathologist from the Oklahoma Department of Education and for licensure as a Speech-Language Pathologist from the Oklahoma Board of Examiners for Speech-Language Pathology and Audiology. Specific requirements listed herein reflect standards from those agencies and/or knowledge and skill competencies and clinical experiences deemed essential to meet the NSU SLP Program’s Mission and goals. Student clinicians are those students who are enrolled in clinical practicum at NSU in the Speech-Language Pathology Program. Typical students will experience 5 semesters of enrollment in practicum. The first 3 semesters include on-campus practicum and possible assignments through NSU at contractual off-site placements (Head Starts, Public Schools…) The last two semesters are comprised of internships and externships at off-campus sites. These sites are assigned and monitored through NSU faculty. The onsite clinical practicum is the beginning of the clinical experience and should be a time to learn and perfect clinical skills. ASHA requires 400 clinical clock hours. Further requirements include a breakdown of these 400 hours in the following categories: 1. Completion of 25 hours of observation before any clock hours may be earned. 2. A minimum of at least 375 clinical clock hours earned while enrolled in graduate

studies at the university 3. 325 of these 375 clinical clock hours at the graduate level The NSU SLP Program requires the following breakdown of the 400 hours required by ASHA plus an additional 25 hours required by NSU. Evaluation Adult speech 20 hours Child speech 20 hours Adult language 20 hours Child language 20 hours Treatment Adult speech 20 hours Child speech 20 hours Adult language 20 hours Child language 20 hours Evaluation/Rehabilitation Audiology 10 hours

This requirement ensures that the hours cover all areas of clinical experiences within speech-language pathology. It is the clinician’s responsibility to keep accurate records of all clinical clock hours. Remember, the time spent in clinic practicum is a learning experience. Clinicians are not expected to know all of the answers. That is why the supervisors are here. Become familiar with all of the information supplied in the handbook and follow these procedures. Student clinician will be viewed as a professional by the client, the families and the supervisors. Answer questions which are posed and if unsure what the answer is-say so-then seek out a supervisor to help find the answer. Any problems with the clients, families, teachers, or fellow clinicians should be reported immediately to the supervisor. Be open

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and honest, but tactful and kind. Do not let a small problem grow into a big one through gossip and inability to confront the problem.

In addition to carrying out clinical/therapy responsibilities and other assignments, attendance at weekly clinical staff meetings and other meetings will be required.

Clinicians are not required to join the local or state organization. The faculty and supervisors do strongly suggest, however, that you take advantage of the professional organization opportunities available to you. It is important that clinicians become involved in the professional organizations in order to keep up with current issues and practices that are happening in the field.

Northeastern Student Speech-Language-Hearing Association (NESSLHA) is the student organization for the NSU SLP Program. As a member of this local organization, clinicians will get to have a voice in the programs and procedures, in addition to having a lot of fun!

The National Student-Speech-Language-Hearing Association (NSSLHA). As a member of the national student organization, clinicians will receive all of the publications of ASHA, all mailings with facts of interest as a professional and discounts when attending professional conferences and when the time comes to join ASHA. Access to these professional journals is an essential part of Evidence-Based Practice.

Student memberships are also available in the Oklahoma Speech-Language-Hearing Association (OSHA). Membership in OSHA makes you eligible for student discounts at the annual OSHA convention and eligible to apply for the OSHA scholarship. Enjoy your time as a student clinician. Learn a lot!!

UNDERGRADUATE OBSERVERS Undergraduate students are required to accrue twenty-five hours of observation of assessment and therapy in speech-language pathology and audiology. These hours must be obtained before clinical clock hours can be completed. These 25 hours are broken down in increments of five hour blocks and completed in five courses. These courses are SLP 3313, Introduction to Communication Disorders; SLP 3813, Language Development; SLP 4783, Articulatory and Phonological Disorders; SLP 3213, Language Disorders; and SLP 3443 Materials and Methods for Clinical Practices. Students must be enrolled in one of these five classes to be eligible to observe in the clinic.

Observers are bound by ASHA’s Ethics and confidentiality guidelines in regards to confidentiality of clients. A documented report of each observed service is required. The form to document the observation will be reviewed in the specific class prior to initiation of the observation. IT IS YOUR RESPONSIBILITY to be sure that the 25 hours are observed. Failure to complete these observation hours will result in consequences reflected in a lower grade in the class.

GRADUATE CLINICIANS

Graduate clinicians provide diagnostic and therapy services during their first year under the supervision of NSU SLP faculty, all of whom have the appropriate CCC and state

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licensure. Students typically earn between 125 to 150 hours of experience during this 12 month period. It is expected that students will receive group therapy experiences in their off-campus sites. Typically, services are provided twice-a-week for 25- to 50- minutes; however, variations from this schedule are allowed to accommodate the client’s needs. Clients are assigned as they become available. In most instances, clients are seen individually

With each passing semester, students are expected to improve in: ■ Therapeutic management of clients. ■ Interview and counseling skills. ■ Diagnostic ability (obtaining data with standardized/normed tests, scaling

procedures, and observation). ■ Maintenance of records, with particular emphasis on clearly written, cohesive,

and coherent reports. After completion of the three semesters in clinic at NSU and upon faculty approval, students will be placed in an internship/externship placement. This site will be approved by faculty and will be supervised by an ASHA certified supervisor with any other credentials required by law or agency policy. These sites include, but are not limited to:

▪ hospitals ▪ schools (state and private) ▪ Sooner Start ▪ nursing homes ▪ private practices ▪ rehabilitation centers

CLIENT POPULATION NSU Speech and Hearing Clinic clients range in age from early preschool children to the

elderly. Presenting problems could include articulation, fluency, voice and resonance, receptive and expressive language, hearing, cognitive aspects, social aspects of communication, communication modalities. Experience with some disorders may be limited to off-campus placements (e.g. swallowing).

CONFIDENTIALITY

NSU CLIENT/PATIENT RECORDS ARE CONFIDENTIAL Procedures:

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● Do not remove client folders or any portion from the building. Faculty, graduate and undergraduate clinicians, and the department secretary have access to the Confidential Client Record.

● “Working copy” of diagnostic reports, semester plans or reports, and lesson plans should not contain the client’s complete name. A first name and final initial, or initials are permissible. Complete identifying information is reserved for final copy.

● Reports, plans, and other client data are only released to other agencies, the legal guardian, or the adult patient upon completion of a Release of Information form.

● Discussion about a client should only be conducted in the privacy of a faculty office or in a clinic room. Discussion should not be overheard by unauthorized listeners.

● Audiotape and video tape recordings of clients are confidential records and are not shared with unauthorized persons and are obtained only after signed permission of the client/patient or parent/guardian.

● HIPAA regulations require a Privacy Policy and a Notice of Privacy Practice outlining the Clinic’s privacy policies be provided to all clients.

CLIENT ASSIGNMENT

Clinical assignments are based on student experience and knowledge, student need

and client availability. Clients are assigned as they become available. The experience needed by the student clinician is a consideration when assignments are made. The client and clinician combination are evaluated using a weighting scale to determine student knowledge and expertise and client severity. The weighting scale is divided into Level 1, Level 2, or Level 3. These levels correlate with the amount of required supervision. Level 1 clients require a minimum of 25% supervision, Level 2 clients require 35 to 40% supervision, and Level 3 clients require at least 50% supervision.

CANCELLATION POLICY

The clinician is expected to attend every scheduled therapy session. Sessions should be cancelled only in cases of extreme emergency or illness or previously approved attendance at professional meetings. The clinician may not cancel sessions without the approval of the supervisor. If the supervisor is unavailable, students should attempt to obtain permission to cancel from the Clinic Director or Program Chair. If the student is unable to contact the supervisor, Clinic Director or Program Chair, he/she may notify the front office of the cancellation. Clinicians are expected to give adequate notification of the cancellation to the client/parent. This cancellation policy should be adhered to strictly. Do not ask the secretary or supervisor to contact the client/parent to cancel the therapy session.

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The weather cancellation policy for the clinic coincides with the Tahlequah Public Schools, Muskogee Public Schools, and Broken Arrow Public Schools weather policy. If those schools are closed due to inclement weather, the therapy and/or diagnostic sessions at the NSU Speech-Language-Hearing Clinic are cancelled. It is the clinician’s responsibility to contact his/her client to confirm weather cancellations.

Excessive Client Absences

The NSU Speech-Language-Hearing Clinic operates primarily to provide clinical experience to NSU SLP students. Excessive client absences will not be tolerated. Clients who miss three sessions without notifying the clinic will be terminated. Any client who misses a therapy/diagnostic session without notifying the clinician or the clinic should be called by the clinician and reminded of the absence policy.

Tracking Clinical Clock Hours Clinical clock hours should be figured consistently. This allows for accurate reports

for ASHA. The following are the guidelines. Clinical clock hours consist of actual face-to-face time spent with the client,

measured in minutes. Preparation, room set-up, clean-up, etc. do not count as part of your clinical clock hour. Allow time for the next clinician to set-up and use the room. Do not begin a session early or end a session early or late without the supervisor’s permission. Make every effort to begin therapy on time and to end the session on time.

Group therapy counts the literal clinical clock hours regardless of number of clients in the group. For example: 3 clients in a group for 30 minutes equals 30 minutes of therapy time, not 30 minutes x 3.

PROFESSIONALISM/DRESS CODE The Northeastern State University Speech-Language-Hearing Clinic provides services to the public. How clients see you will determine to a great extent how they view the quality of the entire clinic, the services received, and the profession. Professionalism is reflected in one’s personal appearance, which includes clothing, grooming, and social manners. The following dress code is required for student clinicians and is to be followed at each clinic supervisor's discretion.

Uniform:

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The Northeastern State University Speech-Language-Hearing Clinic has adopted a clinic uniform which is a Polo shirt with the NSU SLP program logo to be worn with khaki or black pants. If you do not wear the NSU polo please follow the below professional clothing guidelines.

Professional clothing: Professional clothing should be non-distracting and sufficiently sized and constructed not to be revealing. Tops should have a high neckline and long enough tail so as not to expose the midline. Dress conservatively.

● Dresses ● Pant suits ● Slacks/capris ● Blouses/shirts ● Suits ● Skirts (reasonable length) ● Shoes ● Jewelry (simple) ● Closed toe shoes

Unprofessional clothing: Casual, leisure clothes are not acceptable for clinical service.

● Blue jeans, coveralls, t-shirts (with lettering), tank tops, shorts, or jogging clothes ● No spaghetti straps, halter tops, or strapless tops/dresses. ● Clunky, loud shoes; flip flops; tennis shoes (except for off-campus @ supervisor's

discretion) ● Tight clothes with stretch-like fabrics may not be acceptable if you have to tug, pull up or

down, hold, push in or out, or adjust in any way to be discreet. ● Tattoos should not be visible. ● Body piercing jewelry is limited to the ears only. Remove jewelry that is distracting to the

client. ● Avoid perfumes. Many clients may have allergies and be sensitive to heavy fragrances.

*Any exceptions to this policy must have the consent of your Clinical Supervisor. Supervisors have final authority regarding appropriateness of dress.

Professional Language

● Formal address of adults is required for clinic: Dr., Mr., Mrs., and Ms. ● Any type of profanity is unacceptable. ● Proper modeling is essential. Make sure your speech and language reflect the

correct model. ● Be polite. Avoid loud talking and yelling. ● Avoid professional jargon when speaking with clients/parents. If you needed to

memorize the meaning of a term or phrase for an exam, the client/parent will probably not understand it when you use it.

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● Remember to keep clinic information confidential.

Professional Attitude A professional attitude is expressed in the positive way a person accepts and performs assigned tasks, and respects and interacts with supervisor, clients, and peers. The following list consists of some of these positive behaviors.

● Be on time and be prepared for class and clinic. ● Be in a positive frame of mind. ● Recognize that professional duties and situations are about completing tasks and

about solving problems in ways that benefit others, either immediately or in the long term. They are not about you.

● Strive to work effectively with others for the benefit of the persons served. ● Properly credit others for their work. ● Take responsibility for your actions, reactions, and inactions. This means you do

not avoid responsibility by offering excuses, by blaming others, by emotional displays, or by helplessness.

● Do what you say you will do. ● Accept direction and correction. ● Respect others values, interests, and opinions that may differ from yours. ● Adopt evidence-based practice.

Cell phones should be turned off in clinic and class. Exceptions can be made for possible emergencies with prior approval. Mailboxes are provided for each individual clinician and these are used to communicate with each other and to store pertinent papers.

Items that are allowed in your mailbox include: ▪ Therapy materials ▪ Correspondence from NESSLHA ▪ Correspondence from the supervisors ▪ Correspondence from other clinicians Items that are not allowed in your mailbox include: ▪ Confidential files ▪ Any document containing the full name of your client or other identifying

information Please check these continually and maintain a neat appearance.

This space is provided for student clinicians as a privilege. Students are expected to

keep this space neat and clean at all times.

Materials

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Check out tests with the sign out-sign in procedures determined by the clinic director.

1. Turn to the appropriate page for each test. 2. Write your name legibly 3. Place the date of the removal of the test 4. Write the time that the item left the materials room and the estimated time of

return for future clinicians planning to use the material. 5. Place the date of return in the appropriate column. DO NOT TAKE PART OF A TEST (i.e., the manual). THIS IS HOW TEST MATERIALS ARE LOST. EVEN IF YOU ONLY NEED ONE ITEM FROM THE TEST KIT, CHECK OUT THE ENTIRE KIT AND KEEP THE ENTIRE KIT TOGETHER. TESTS MAY BE CHECKED OUT OVERNIGHT BUT MUST BE RETURNED THE NEXT MORNING BY 8:30 A.M.

Check out therapy material on the clipboard:

1. Place name under the clinician heading. 2. Write legibly the title or description of the item in use under materials 3. Write the correct date of removal of the item. 4. Write the time that the item left the materials room. 5. Write the estimated time of return for the item (this is very important for

others trying to use these items and for planning). 6. Place the date of return in the appropriate column.

Check out audiometric equipment in the Check-Out book located in the Diagnostic room.

1. Indicate which equipment is being checked out. 2. Write your name & the date legibly.

AUDIOMETERS MAY BE CHECKED OUT OVERNIGHT BUT MUST BE RETURNED THE NEXT MORNING BY 8:30 A.M. DO NOT LEAVE AUDIOMETRIC EQUIPMENT IN YOUR CAR. EXPOSURE TO HEAT AND COLD CAN BE DETRIMENTAL TO THE EQUIPMENT AND RESULT IN IT BEING INOPERABLE OR PROVIDING INCORRECT INFORMATION.

CLINICAL SAFETY/HEALTH STANDARDS FOR SLP’S/AUD’S

(This information based on literature from ASHA Desk Reference Vol. 4 pg.123-126.) General Procedures: In spite of extremely low risk of transmission of HIV or other infectious diseases the following precautions should be followed:

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Clinical Equipment and Materials Decontamination. Cleaning, disinfection, and sterilization of multiple-use equipment before reuse should be carried out according to the Center for Disease Control (CDC) recommendations. They are as follows. All work areas and surfaces should be cleaned after each use. Clinical materials may be cleaned with simple soap and water or, according to CDC, a 1:100 solution of household bleach to water. In direct client care, disposable materials should be used whenever possible and never reused. It is best to use disposable or cleanable materials during all evaluation and treatment procedures. The underlying assumption regarding all testing materials is, if there is a likelihood that these items may come into contact with blood or body fluids bearing blood, the Universal Precautions must be followed. Speech-language pathologists and audiologists who are not associated with any health care division are encouraged to contact their local health departments if there are any questions regarding maintenance of clinical materials.

Hand washing

Speech-language pathologists and audiologists should follow the same procedures as outlined in the AIDS/HIV publication. These procedures are summarized below: ● Wash hands immediately if they are potentially contaminated with blood or body fluids

containing visible blood. ● Wash hands before and after seeing clients. ● Wash hands after removing gloves. ● Follow the basic hand washing technique:

-vigorous mechanical action whether or not a skin cleanser is used; -use of antiseptic or ordinary soap under running water; -duration of 30 seconds between clients if not grossly contaminated and in handling client devices; -duration of 60 seconds when in contact with clients, devices, or equipment with gross contamination; -thorough hand-drying with a paper or disposable towel to help eliminate germs.

Gloves

● Wear gloves when touching blood or other body fluids containing visible blood. ● Wear gloves when performing invasive procedures on all clients. This includes

performing an examination of the oral speech mechanism, managing tracheostomy tubes, using laryngeal mirrors, conducting intraoperative monitoring, and using needle electrodes associated with EMG testing.

● Change gloves after contact with each client. ● If a glove is torn or a needle stick or other injury occurs, remove the glove and use a

new glove as promptly as client safety permits. ● After removing gloves, wash hands immediately.

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● Discard gloves in the client’s room or examination room before exiting. No special disposal containers are necessary unless gloves are contaminated with blood or bloody fluids.

● Wear gloves if the client has non intact skin or open cuts, sores, or scratches. ● Begin all audiometric procedures with an otoscopic inspection of the circumaural

region and ear canal. If the patient’s skin is intact and no blood is present, gloves are not required for industrial audiometry and fitting hearing protectors. If blood or lesions are found, then 1 minute of vigorous hand-washing followed by use of gloves is required.

Urine and Feces Speech-language pathologists and audiologists do not routinely have contact with urine and feces. However, the following guidelines should be adhered to when there is risk of contamination by blood: ● Flush urine and feces down the toilet. ● If you handle urinals or empty catheter bags or bedpans, wear gloves. ● If it is necessary to use a portable urinal, bedpan, or commode, empty it into the toilet

and thoroughly clean and sanitize before replacing it at the client’s bedside or returning it to storage.

● When changing diapers, wear gloves. Dispose of soiled diapers.

Food Utensils and Containers ● No special food or disposal precautions are required unless the food has been

contaminated with blood or body fluids containing visible blood. ● No special precautions are required, except for proper disposal/disinfection of the

cup/straw.

Clothing and Personal Effects ● No special precautions are required unless contaminated-lab coats, smocks, washable

clothing should be cleaned regularly. ● Launder all contaminated clothing and effects.

Observation and Significant Other/Family Participation ● Ensure compliance with Universal Precautions when family members and others are

present to observe any procedure where they may be exposed to client’s blood or body fluid containing visible blood.

● Ensure family training in Universal Precautions when a significant other is being trained to conduct follow-up procedures where he/she may be exposed to client’s blood or body fluid containing visible blood.

Daily Cleaning and Terminal Disinfection Procedures ● Daily cleaning procedures should be clearly specified in the facility’s policies and

procedures. These should detail any waste disposal procedures as well as procedures

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to inform housekeeping, if applicable. If speech-language pathologists and audiologists dispose of needles and infectious waste, special cleaning protocols are indicated.

Cleaning/decontaminating Spills and/or Splashes of Blood or Other Body Fluids Containing Visible Blood: When housekeeping personnel are not available, practitioners should: ● Wear a pair of gloves, goggles, and a gown. ● Remove visible materials first. ● Use disposable toweling. ● Decontaminate areas of flooding with liquid germicide. ● Clean surface with a freshly prepared 1:10 hydrochloride (household bleach) solution

(1 part bleach to 10 parts water).

Cleaning of Rooms and Therapy Materials

1. Clean tabletops and work surfaces in the treatment rooms at the beginning and end of each treatment or diagnostic session with cleaning solution provided.

2. Clean play materials and therapy materials at the beginning and end of each treatment or diagnostic session with cleaning solution provided.

This is the responsibility of each clinician and will be factored into the clinician’s grade.

CPR Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth to mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be strategically located and available for use in areas where the need for resuscitation is predictable. The American Heart Association (1989) has recently provided supplemental guidelines for CPR Training and Rescue and discourages even individuals who are CPR certified from administering mouth to mouth resuscitation without benefit of some barrier device. CPR should be administered only by trained individuals who have the benefit of a barrier or ventilation device. CPR mouth devices are kept in the clinic area (in the main hallway of the clinic) and in the front office. (This information is based on literature from ASHA Desk Reference Vol. 4 pg.123-126.)

NSU CLINIC PROCEDURES

CONFIDENTIALITY NSU CLIENT/PATIENT RECORDS ARE CONFIDENTIAL

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Confidentiality is one of THE most important aspects of clinical ethics and professional conduct. All information concerning past or present clients is strictly confidential. Specifically the following information is not to be divulged. Confidential information can only be released with appropriate written permission from a client or parent/guardian for children under the age of 18.

1. Name of client. 2. Type or nature of the problem. 3. Family information. 4. Any identifying information concerning the client. 5. A tape recording of the client’s speech. 6. Lesson plans for therapy sessions. 7. Test results or other diagnostic information. 8. Observation reports. 9. Rough draft or final of clinical reports.

Confidentiality guidelines will be dispersed and reviewed. A confidentiality statement will be signed indicating that the clinician has read, understands and agree to adhere to the confidentiality guidelines.

General Guidelines for confidentiality procedures: 1. Do not discuss clients outside of the clinic. Our hallway and waiting area is a

thoroughfare with parents, clients, and other students passing through frequently.

2. Never discuss clients with your family and friends. 3. Only those involved with the child’s program have access to confidential

information. (i.e. Department faculty, supervisors, assigned clinicians, and appropriate personnel of contract agencies {Head Starts, Sequoyah High School, etc.}.) These people should be asked to sign the Confidential Record in front of the folder. Custodial parents, guardians and clients over the age of 18 may see confidential information upon request. If you are in doubt, ask your supervisor.

4. When sharing ideas, problems, etc. with fellow clinicians and supervisors make sure you maintain confidentiality. This helps prevent talking about problems with others.

CONDITIONS THAT ARE MOST LIKELY TO CAUSE CONFIDENTIALITY PROBLEMS ARE THE FOLLOWING:

1. Conversations with other professionals who have a need to know, but the parents/clients have not given permission to divulge information to other individuals.

2. Promotion and publicity for the clinic. 3. Recordings of the client’s speech that are taken out of the clinic for analysis and

might be overheard by roommates and friends. Lesson plans, observation reports or diagnostic information that might be left in notebooks or on desks where others could read them.

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4. Really interesting or sensational cases that should never be discussed no matter how tempting

5. Posting anything about clinic experiences on social media 6. Leaving text messages or voicemail about clients – (You should only give your

name, the call back number, and an indication that you are from the NSU Speech-Language-Hearing Clinic. Do not leave the client's name or any other information about the client.)

Graduate Clinicians Protocol

A. Assignment: 1. All client assignments will be made by the Clinic Director/Assistant Clinic

Director. 2. Read and familiarize yourself with all material in the client folder. 3. Client should be contacted within 24 hours. The following is a suggested

scenario. This is Miss/Mr. ____________ from Northeastern State University Speech-Language-Hearing Clinic. I have been assigned as the speech-language clinician for ____________. Is this a convenient time to discuss a weekly therapy service for ____________? Determine the best time to provide the service as recommended in the diagnostic report or the previous semester, or your supervisor.

Report one of four conclusions from telephone calls to schedule client. 1. I have reached the client and they are scheduled. 2. I have reached the client and we are working on a schedule. 3. I have sent the client a letter regarding the schedule. 4. The client declined services and a casenote has been placed in the folder.

If unable to contact by phone, mail form letter with 2 days of assignment.!!! Be careful about leaving messages. See # 6 above.

B. Flow Chart for sequence of therapy and paperwork (see appendix)

1. Review folders. (confidential folders in front office) a. Confidential folders should be filed alphabetically by client’s last

name. b. Be sure the name on label is easily seen. c. Neatness.

i. Replace torn file folders. ii. Align forms, etc. appropriately so that no papers must be folded or

trimmed. iii. Complete all identifying information at the top of the new page.

2. Plan pre-testing 1st session re-introduce yourself

a. make the client comfortable-you must appear at ease and in control (the following is an example dialogue-“Hello, I’m Carol Smith, a student/graduate student in speech-language pathology. I’m

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pleased you can be here today. My supervisor is _________. She/he will observe my work on a regular basis to ensure it is correct. Have you met (observation student.) Did you have any problems finding a place to park? And/or I appreciate you being so prompt/on time etc.

Avoid asking the child the following: 1. “Do you want to come with me to therapy?” 2. “ Is it okay for mother to wait out here?”

Try instead: 1. “Come to the room with me so we can work/play.” 2. “Mother will wait for us here.” (first session)

b. introduce/re-introduce yourself i. Tell what you will be doing very briefly (be careful about speaking

in front of children) ii. Observe for strengths (overall behavior, target behavior, alternate

communication methods) iii. Be sure and communicate after each session-their behavior,

progress towards goals and any homework. Try to establish next session. “I will see you next Wed. at 4:00.” A BRIEF SUMMARY OF THESE POINTS SHOULD BE ADDRESSED AFTER EACH SESSION.

3. General Information:

a. Questions about the client should be answered by you or by your supervisor.

b. Inform adults and older children that services will be observed by supervisory staff, and graduate/undergraduate students. This is because we are a training center. Parents and older clients can request no observers: this must be cleared with the supervisor.

4. Complete necessary paperwork: a. begin introduction of progress report b. fill out daily therapy log c. fill out practicum log d. fill out attendance log

MEET WITH SUPERVISOR WHEN NECESSARY!!!

DURING NEXT SESSIONS 5. Continue pre-testing and creating semester plans (second session). 6. Turn in semester plans before the third session and begin continuing creating semester programs. 7. Begin therapy and continue creating semester programs (third session). 8. Complete audiological screening-complete forms and recommendations.

C. Confidential Folders-folders should contain the following paperwork:

1. Record of Access to Educational Information

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a. Staple all corners to the inside left of the folder. b. Complete identifying information. c. Must be signed by anyone who reviews the folder each time

the folder is reviewed. Should include the date and purpose (i.e. initiate folder, insert information, review information, attempt contact, conference, etc. 2. Record of Parent Contact

a. Form always remains on top of the right side. b. Complete identifying information. c. Document all attempts to contact parents as well as those contacts

which were unsuccessful. 3. Progress Reports

a. Past completed progress reports should be placed in order in the folder from most recent to least recent.

b. Current working progress reports should be kept in a daily folder in the supervisor's office with other working forms.

c. Progress reports should contain past tense form and third person pronouns. There should not be any use of first or second person pronouns.

4. Attendance Sheets

a. Past completed attendance sheets should be placed in the confidential folder at the end of semester.

b. Current attendance sheets should be kept in a daily folder in the supervisor's office with other working forms.

5. Diagnostics a. All diagnostics should be placed in order from most recent to least

recent in the diagnostic section of the confidential folder. b. Any other diagnostic material from an outside agency should be

placed in the diagnostic section in order from most recent to least recent.

6. Testing Material a. The actual test protocols are always placed in the folder in order from

most recent to least recent in the test protocol section. b. All audiograms should be placed in the folder along with the test

protocols. 7. Consents/Releases

a. There should be a consent, allowing for the SLP services. This consent also includes an attendance policy. Always check to make sure the consent is dated and witnessed.

b. There may be a need for releases if the client is receiving services or has received services at another health agency. These releases should also be dated and witnessed and filled out in their entirety.

c. There should be a HIPAA notice, indicating that the client has been apprised of his/her rights and that the Speech-Language-Hearing Clinic and the clinician agrees to abide by these.

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DIAGNOSTIC GUIDELINES/REGULATIONS Purpose of a diagnostic session

● The purpose is to collect objective and subjective data to determine the patient’s current speech-language status. This requires analysis and interpretation of the data to make a diagnosis, prognosis, and recommendations for management.

Before the session Order of activities:

1. You will be assigned a client to evaluate. You will be given the name, birth date, contact information, and complaint.

2. You will meet with your supervisor 2 to 3 days before the evaluation date with suggestions and rationale for test selection.

3. You should be familiar with the tests you choose. 4. Your supervisor will make the final test selections. 5. You must practice administering the tests before the evaluation session. 6. You must prepare the testing room by arranging a table and chairs, cleaning the

table and chairs, turning on the sound system, and collecting and organizing all tests and materials including recorders and tapes.

7. Ask the secretary for a new diagnostic folder with all the forms (AKA dummy file). 8. Fill out identifying information prior to the evaluation.

During the session Order of activities:

1. The session begins the minute the client arrives until the time he/she leaves. 2. Begin the session only after you have received permission from your

supervisor. 3. Introduce yourself and the supervisor to the client/parent. Example: “Good

afternoon. I’m Carol Smith, a graduate student in speech-language pathology. Let me introduce you to Dr./Mrs./Mr. _______, the faculty member who will supervise today’s service. Inform them of the location of the restrooms and water fountain.

4. Escort the client to the testing room and indicate where he/she is to sit. 5. Before testing, explain, complete, set the fee, and sign the CONSENT FOR

EVALUATION and AGREEMENT FOR PAYMENT form, the RELEASE OF INFORMATION form, and the DISCLOSURE STATEMENT AND EXPRESS ASSUMPTION OF RISK form. Give the client/parents a copy of the HIPPA notice and Confidentiality/Privacy Notice.

6. Be sure to inform the client that (1) he/she will be recorded, (2) graduate students will be conducting the services under supervision, and (3) students may be observing.

7. Turn on the video and/or audio recording units.

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8. Inform the client/parent of the length of testing and what you plan to accomplish during the session.

9. PRE-TEST INTERVIEW. Request the client/parent to fill out the case history form if he/she has not already done so. Following the completion of the case history form, review the information with the client/parent. There may be a need to expand on certain areas, which contribute to or influence the patient’s admitting condition. It is also important to ask the client/parent at the completion of the interview if there is any other information that they may want to add that may not have been addressed.

10. Ask the client/parent if they want to remain in the evaluation room during testing, to observe, or to wait in the waiting area.

11. Begin the evaluation and continue until you have administered all the tests/tasks you were assigned. You may need to give the client breaks if testing is too long.

12. When you finish the diagnostic session, direct the parent and child, or adult client to the waiting area. Explain that you must meet with your supervisor to review test information and recommendations. Score and interpret the data with your supervisor and determine the appropriate management of the client. Make recommendations and discuss those recommendations with your supervisor.

13. Meet with the parent or adult client and interpret, explain, and clarify the findings and the recommendations. Use common terms instead of professional jargon. Remember that numbers, percentages, decibels, hertz, standard scores, etc. may not be meaningful to them.

14. ALL DISCUSSION IN RELATION TO THE SERVICE IS CONDUCTED IN THE CLINIC. NO ASPECT OF THE INTERVIEW OR SUMMATION IS DONE IN THE HALLWAY, WAIT AREA, OR DEPARTMENT OFFICE.

15. Inform the client/parent that you are finished with the service. Thank them for coming to our Clinic and let them know that they may call us if they have any questions about the service.

16. Complete all forms from the clinic director. Report Writing The report must be accurate, clearly written, and organized. Information should be easy to find.

1. The initial copy is due 48 hours after the service. 2. Double space the initial and all reports submitted for revision. State the client’s

first name and initial of the last name until the final draft. Correct spelling, grammar, syntax, and punctuation are very important.

3. Submit the initial draft with all protocols in the client’s folder to your supervisor in person.

4. Include the previous revision with each new revision. Don’t be upset if you have to rewrite several times.

5. Always write in past tense and third person.

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The report should include: Identifying Information Client Name Date of Birth Parents/Spouse Address

Telephone Date of Evaluation Student Clinician Supervisor

Statement of the Problem

Introductory paragraph should include the client's name, age, type of evaluation received and date, the statement of the problem, the referral source, reason for referral, and who accompanied the client. Example: “Joe Jones, a 4-year-old male, received a speech and language evaluation on March 5, 2006, at the Northeastern State University Speech-Language-Hearing Clinic. He was accompanied by his mother, Janet Jones, who stated, “Joe does not say his ‘r’ letters right.”

Background Information

Report only pertinent information that could come from referral letters, case history, and the parent/client interview (including pre-,para-, post-natal, motor development, health, education, social/family, other professional services) (Pannbacker, et al, 2001). Always indicate the source of your information (“The client/parent reported that … or Records from the school indicated …”).

Tests Administered Summarize the test/tests used for evaluation Test Results

The evaluation should include information pertaining to client’s speech, language, oral examination, hearing, and behavior. Summarize the findings of the evaluation and scores. Use language that all readers will understand. It may be helpful to briefly describe how the client responded. The report should contain information about all aspects of the client’s communication behavior.

Behavioral Observations Include information regarding the client’s behavior and its influence on the validity of the test results. Describe the child’s behaviors instead of interpreting them. Conclusions

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Summarize and integrate the information from the history and tests administered. Include a disorder classification, a specification of severity, statement of the cause of casual-related factors influence on the diagnosis (Meitus, 1983).

Recommendations This section is used to translate our findings into appropriate suggestions or directions that will help the client solve communication and related problems” (Haynes and Pindzola, 1998, p. 296). Recommendations should be specific and brief. “They may include recommendations for treatment, parent training or counseling, reevaluation, and referral” (Pannbacker, 2001. p. 32).

Signatures

Type a signature line for the examiner(s) and supervisor. Under the signature line type, the person’s name, title and professional qualifications.

References: Meitus, I.J. and Weinberg, B. (1983). Diagnosis in Speech-Language Pathology. Baltimore, University Park Press Haynes, W.O. and Pindzola, R.H. (1998). Diagnosis and evaluation in Speech-Language Pathology, Fifth edition. Boston: Allyn and Bacon Pannbacker, M., Middleton, G., Vekovius, G.T., & Sanders, K.L. (2001). Report writing for Speech-Language Pathologists and Audiologists, second edition. Austin: Pro-ed

FLOW CHART FOR SPEECH AND LANGUAGE THERAPY

REVIEW MATERIAL

(DIAGNOSTICS AND PAST REPORTS)

PLAN PRE-TESTING

(FIRST SESSION) COMPLETE PRE-TESTING AND INITIATE

SEMESTER PLANS

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(SECOND SESSION) CONTINUE PRE-TESTING AND CREATING

SEMESTER PLANS

TURN IN SEMESTER PLANS AND BEGIN CREATING SEMESTER PROGRAMS

(THIRD SESSION)

BEGIN THERAPY AND CONTINUE CREATING SEMESTER PROGRAMS

(FOURTH SESSION)

TURN IN SEMESTER PROGRAMS NSU Speech\Language\Hearing Clinic Deadlines

Item Due Semester Plan After the clinician has seen the client twice Semester Therapy Program After the clinician has seen the client four times Progress Reports (first draft) On Wednesday of the last week of therapy Progress Reports On Tuesday of Finals Week (final typed &

approved Diagnostic Reports On the first Wednesday after diagnosis was

administered or to be announced if scheduled with another supervisor

Letter to the referring party for the diagnosis

On day of diagnosis

Diagnostic Reports (typed and sent out to parties requested)

Within 15 working days of the diagnostic

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NSU AUDIOLOGY GUIDELINES

For Practicum in Speech-Language Pathology

NOTE: All universal precautions and confidentiality guidelines and regulations apply to audiology clinical practicum.

Speech-Language Pathologist may administer screening of individuals for hearing loss or middle ear pathology using conventional pure-tone air conduction methods (including otoscopic inspection), otoacoustic emissions screening, and/or screening tympanometry. (Updated according to ASHA 2007 Scope of Practice) Clock Hour Credit: You can receive clock hour credit for all adequately supervised active time that is spent in screening individuals. Hearing screening can be supervised by either an audiologist with CCC-A or a speech-language pathologist with CCC-SLP. Clinical Process PURE TONES: Screening for hearing impairment consists of pure tones presented via earphones at 1000, 2000, and 4000, and 500 Hz at 20 dB HL for children (ages 3-18) via conventional or conditioned play audiometry, and at 25 dB HL for adults.

● Patients/clients who do not respond at any frequency in either ear are rescreened if possible.

● Patients/clients who do not respond at any frequency during the re screen are referred to an audiologist for an audiologic evaluation.

VISUAL INSPECTION, OTOSCOPY, TYMPANOMETRY: Patients/clients with observable anomalies of the outer ear, ear canal or tympanic membrane and/or abnormal tympanograms are referred for medical and/or audiologic follow-up determined by the supervisor. The following guidelines should be considered when determining follow-up referrals

● Patients/clients with a Type B tympanogram and a small volume should be referred for medical evaluation, especially if there is a history of ear infections or cerumen impaction.

● Patients/clients with a Type B tympanogram and a large volume should be referred for medical evaluation unless PE tubes can be visualized during otoscopy or patient/parent reports the presence of tubes.

● Patients/clients with a Type C tympanogram should be rescreened in 1-2 weeks. ● Patients/clients with a Type Ad tympanogram with abnormal pure tone results

should be referred for audiologic evaluation. ● Patients/clients with a Type Ad tympanogram, normal pure tone results & a history

of ear infections pass the screening. ● Patients/Clients with a Type As tympanogram and absent reflexes should be

referred for audiologic evaluation.

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Screening for hearing disability is conducted by interview, case history, and/or questionnaire. Screening services are sensitive to cultural and linguistic diversity. OTOACOUSTIC EMISSION SCREENING Screening using otoacoustic emissions can be completed on either children or adults.

● Patients/clients on whom otoacoustic emissions cannot be elicited should be referred for audiologic evaluation.

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Northeastern State University Speech-Language-Hearing Clinic

Confidentiality/Privacy Policy The Northeastern State University Speech-Language-Hearing Clinic regards client/patient privacy with the utmost respect and does not disseminate any client/patient information without express written releases from the adult client/patient or from the parent/legal guardian of a child client/patient under the age of 18. Confidentiality/ privacy of client/patient information is governed by federal law (The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191), the Code of Ethics of American Speech-Language-Hearing Association, and the Code of Ethics of the Oklahoma State Board of Examiners for Speech-Language Pathology and Audiology. The Northeastern State University Speech-Language-Hearing Clinic operates as part of the NSU Speech-Language Pathology Program. As part of this educational program, students observe clients/patients and provide direct services to clients/patients under the supervision of NSU SLP faculty. All NSU Speech-Language Pathology students, employees and faculty members are subject to this confidentiality/privacy policy. Students who have access to client/patient sessions and/or client/patient information are instructed in confidentiality/privacy regulations and sign a confidentiality/privacy agreement indicating that they will abide by the NSU Speech-Language-Hearing Clinic confidentiality/privacy policy. Also as part of the educational program, information from the clinic may be discussed in classes. In such cases, identifying information (such as the client’s full name) is not disclosed and students who are participating in the class must have a signed confidentiality/privacy agreement on file. All clients/patients (or their parents/legal guardians in the case of children under the age of 18) will be given a copy of the Confidentiality/privacy policy as well as a Notice of Privacy Practices which includes details on how the NSU SLP Clinic collects, uses and discloses patient information and will be asked to sign a form indicating that they have been provided with this information. The Northeastern State University Speech-Language-Hearing Clinic considers misuse of private information as a serious offense that could result in consequences ranging from reprimand to termination of student, employee or faculty member.

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NORTHEASTERN STATE UNIVERSITY SPEECH-LANGUAGE-HEARING CLINIC

TAHLEQUAH, OK 74464

Client___________________________ Number_________________________

DISCLOSURE STATEMENT AND EXPRESS ASSUMPTION OF RISK

The State of Oklahoma through the Board of Examiners for Speech Pathology and Audiology and the American Speech-Language-Hearing Association requires all applicants for certification and licensure to practice speech/language pathology to take part in a practicum experience. This involves providing diagnostic and therapy services under the supervision of certified faculty. These services will be provided to you at a nominal fee. We wish to make it clear that the person providing direct therapy and diagnostic service is NOT licensed in Oklahoma and is a student clinician completing licensure requirements. Neither the Board of Regents of Northeastern State University nor any of its agents or employees can assume responsibility or liability for the services you receive. This is a training clinic, and as such faculty and/or other students may observe diagnostic and/or therapy sessions and audio and/or video tapes may be made of sessions and may be used for instructional purposes.

LIMITATION OF LIABILITY

I, the undersigned, verify that I have read and understand the above disclosure statement. I understand that the Board of Regents of Northeastern State University, its agents, and employees are not responsible for any acts, omissions, or negligence committed by student clinicians during the course of diagnosis or treatment and no representations or statements have been made to me about the skill or competence of any student clinician or the result of treatment I will receive. I understand that, in the event of physical injury resulting from any activities conducted in this clinic, neither financial compensation nor free medical treatment is provided for such a physical injury. I further understand that, as a training clinic, these sessions may be directly observed by other students and/or faculty and those audio and/or video tapes may be made of sessions for instructional purposes. In addition, I agree that photographs and/or video tapes may be made and used for the following purposes: ____Release to newspapers to familiarize the public with services provided in the clinic. ____Brochures that are sent to prospective students or school counselors and/or administrators. ____Brochures used by the NSU Development Foundation for fundraising purposes to improve clinical facility. ____Television and/or film presentations to publicize the services provided by this clinic. ____video client for educational purposes. _________________________________ _______________________________ Client’s Name Signature of Client or Parent _________________________________ _______________________________ Address Date Signed _________________________________ _______________________________ Witness Telephone Number

NORTHEASTERN STATE UNIVERSITY SPEECH-LANGUAGE CLINIC

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CONFIDENTIALITY INFORMATION Pledge of Confidentiality: Confidential information, or data, is defined as “any information where the individual described is named or otherwise identifiable.” As a condition for my access to the confidential data of Northeastern State University Speech-Language Clinic, I agree to uphold the confidentiality of the data in accordance with the following requirements:

1. I will avoid any action that will provide confidential information to unauthorized individuals or agencies.

2. I will not scan or review any NSU Clinic records or files for which I do not have specific authorization.

3. I will not make copies, or physically remove, any confidential NSU Clinic records, except as specifically authorized.

4. All confidential data in my possession will be maintained in a safe manner which restricts unauthorized individuals from access.

5. I will not discuss information that might lead to identification of individuals described in the NSU Clinic files with any unauthorized person.

6. I will limit my use of confidential NSU Clinic data to the purposes for which I have been specifically authorized.

7. I will not give my password(s) or file access codes to any unauthorized person. 8. If I become aware of my unauthorized access to, or divulgence of confidential NSU

Clinic data by someone else, I will report it immediately to my supervisor. I understand that failure to report violations of confidentiality by others is just as serious as my own violation and may subject me to legal prosecution.

I understand that if I fail to keep my pledge of confidentiality I will be subject to legal prosecution. Any use, release, or publication of healthcare data contrary to the provision stated may result in civil and or criminal liability. _______________________________ __________________ Signature of Student Date _______________________________ Print or Type Name _______________________________ __________________ Witness (NSU SLP Supervisor or faculty member) Date Revised 2/06

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EFFECTIVE DATE 04/14/2003 NOTICE OF PRIVACY PRACTICES

Northeastern State University Speech-Language-Hearing Clinic

800 N. Vinita Tahlequah, OK 74464

(918) 456-5511 ext.3782 (918) 458-9605 fax

Public Information Officer: Mrs. Lisa Jo Roach, M.Ed., CCC-SLP, Clinic Director ______________________________________________________________________________________

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. ______________________________________________________________________________________

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your speech-language-hearing abilities; referring you to another specialist; or getting copies of your health information from another professional that you may have seen before us. “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: internal quality assurance; personnel decisions; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.

● USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information

without your permission. Not all of these situations will apply to us; some may never come up at our

office at all. Such uses or disclosures are:

● when a state or federal law mandates that certain health information be reported for a specific

purpose;

● for public health purposes, such as contagious disease reporting, investigation or surveillance; and

notices to and from the federal Food and Drug Administration regarding drugs or medical devices;

● disclosures to governmental authorities about victims of suspected abuse, neglect or domestic

violence;

● disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders

of courts or administrative agencies;

● disclosures for law enforcement purposes, such as to provide information about someone who is or

is suspected to be a victim of a crime; to provide information about a crime at our office; or to report

a crime that happened somewhere else;

● uses or disclosures for health related research;

● uses and disclosures to prevent a serious threat to health or safety;

● uses or disclosures for specialized government functions, such as for the protection of the president

or high ranking government officials; for lawful national intelligence activities; for military purposes;

or for the evaluation and health of members of the foreign service;

● disclosures of de-identified information;

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● disclosures relating to worker’s compensation programs;

● disclosures of a “limited data set” for research, public health, or health care operations;

● incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;

● disclosures to “business associates” who perform health care operations for us and who commit to

respect the privacy of your health information;

● uses and disclosures to be utilized in our facility directory. Our facility directory is used to let

someone that came with you to your appointment know the status of your care within our facility

that day. For example if your friend or family member asks how much longer you will be with your

appointment.

Unless you object, we will also share relevant information about your care with your family or friends who are helping with speech-language-hearing services.

APPOINTMENT REMINDERS We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can:

● ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment),

payment or health care operations. We do not have to agree to do this, but if we agree, we must

honor the restrictions that you want. To ask for a restriction, send a written request to the office

contact person at the address or fax shown at the beginning of this Notice.

● ask us to communicate with you in a confidential way, such as by phoning you at work rather than at

home, by mailing health information to a different address, or by using Email to your personal EMail

address. We will accommodate these requests if they are reasonable, and if you pay us for any extra

cost. If you want to ask for confidential communications, send a written request to the office contact

person at the address or fax shown at the beginning of this Notice.

● ask to see or to get photocopies of your health information. By law, there are a few limited situations

in which we can refuse to permit access or copying. For the most part, however, you will be able to

review or have a copy of your health information within 30 days of asking us (or sixty days if the

information is stored off-site). You may have to pay for photocopies in advance. If we deny your

request, we will send you a written explanation, and instructions about how to get an impartial

review of our denial if one is legally available. By law, we can have one 30 day extension of the time

for us to give you access or photocopies if we send you a written notice of the extension. If you want

to review or get photocopies of your health information, send a written request to the office contact

person at the address or fax shown at the beginning of this Notice.

● ask us to amend your health information if you think that it is incorrect or incomplete. If we agree,

we will amend the information within 60 days from when you ask us. We will send the corrected

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information to persons whom we know received the wrong information, and others that you specify.

If we do not agree, you can write a statement of your position, and we will include it with your health

information along with any rebuttal statement that we may write. Once your statement of position

and/or our rebuttal is included in your health information, we will send it along whenever we make a

permitted disclosure of your health information. By law, we can have one 30 day extension of time to

consider a request for amendment if we notify you in writing of the extension. If you want to ask us

to amend your health information, send a written request, including your reasons for the

amendment, to the office contact person at the address or fax shown at the beginning of this Notice.

● get a list of the disclosures that we have made of your health information within the past six years (or

a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment,

payment or health care operations; disclosures with your authorization; incidental disclosures;

disclosures required by law; and some other limited disclosures. You are entitled to one such list per

year without charge. If you want more frequent lists, you will have to pay for them in advance. We

will usually respond to your request within 60 days of receiving it, but by law we can have one 30

day extension of time if we notify you of the extension in writing. If you want a list, send a written

request to the office contact person at the address or fax shown at the beginning of this Notice.

● get additional paper copies of this Notice of Privacy Practices upon request. It does not matter

whether you got one electronically or in paper form already. If you want additional paper copies,

send a written request to the office contact person at the address or fax shown at the beginning of

this Notice.

OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Website.

COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to

complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address or fax shown at the beginning of this Notice. If you prefer, you can initiate your complaint in person or by phone, to be followed by a written statement.

FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person at the

address or phone number shown at the beginning of this Notice. Revised 9/18

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ACKNOWLEDGEMENT OF RECEIPT I acknowledge I received a copy of the NSU Speech-Language-Hearing Clinic Notice of Privacy Practices.

Patient name ___________________________________________________________________________

Signature ______________________________________________ Date _____________________ Witness _____________________________________________ Date ______________________

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Code of Ethics Reference this material as: American Speech-Language-Hearing Association. (2015). Code of Ethics [Ethics]. Available from www.asha.org/policy. Index terms: ethicsdoi:10.1044/policy.ET2010-00309 © Copyright 2015 American Speech-Language-Hearing Association. All rights reserved. Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

Preamble

The American Speech-Language-Hearing Association (ASHA; hereafter, also known as "The Association") has been committed to a framework of common principles and standards of practice since ASHA's inception in 1925. This commitment was formalized in 1952 as the Association's first Code of Ethics. This Code has been modified and adapted as society and the professions have changed. The Code of Ethics reflects what we value as professionals and establishes expectations for our scientific and clinical practice based on principles of duty, accountability, fairness, and responsibility. The ASHA Code of Ethics is intended to ensure the welfare of the consumer and to protect the reputation and integrity of the professions.

The ASHA Code of Ethics is a framework and focused guide for professionals in support of day-to-day decision making related to professional conduct. The Code is partly obligatory and disciplinary and partly aspirational and descriptive in that it defines the professional's role. The Code educates professionals in the discipline, as well as students, other professionals, and the public, regarding ethical principles and standards that direct professional conduct.

The preservation of the highest standards of integrity and ethical principles is vital to the responsible discharge of obligations by audiologists, speech-language pathologists, and speech, language, and hearing scientists who serve as clinicians, educators, mentors, researchers, supervisors, and administrators. This Code of Ethics sets forth the fundamental principles and rules considered essential to this purpose and is applicable to the following individuals:

● a member of the American Speech-Language-Hearing Association holding the Certificate of Clinical Competence (CCC)

● a member of the Association not holding the Certificate of Clinical Competence (CCC)

● a nonmember of the Association holding the Certificate of Clinical Competence (CCC)

● an applicant for certification, or for membership and certification

By holding ASHA certification or membership, or through application for such, all individuals are automatically subject to the jurisdiction of the Board of Ethics for ethics

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complaint adjudication. Individuals who provide clinical services and who also desire membership in the Association must hold the CCC.

The fundamentals of ethical conduct are described by Principles of Ethics and by Rules of Ethics. The four Principles of Ethics form the underlying philosophical basis for the Code of Ethics and are reflected in the following areas: (I) responsibility to persons served professionally and to research participants, both human and animal; (II) responsibility for one's professional competence; (III) responsibility to the public; and (IV) responsibility for professional relationships. Individuals shall honor and abide by these Principles as affirmative obligations under all conditions of applicable professional activity. Rules of Ethics are specific statements of minimally acceptable as well as unacceptable professional conduct.

The Code is designed to provide guidance to members, applicants, and certified individuals as they make professional decisions. Because the Code is not intended to address specific situations and is not inclusive of all possible ethical dilemmas, professionals are expected to follow the written provisions and to uphold the spirit and purpose of the Code. Adherence to the Code of Ethics and its enforcement results in respect for the professions and positive outcomes for individuals who benefit from the work of audiologists, speech-language pathologists, and speech, language, and hearing scientists.

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Principle of Ethics I Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.

Rules of Ethics

1. Individuals shall provide all clinical services and scientific activities competently. 2. Individuals shall use every resource, including referral and/or interprofessional

collaboration when appropriate, to ensure that quality service is provided. 3. Individuals shall not discriminate in the delivery of professional services or in the

conduct of research and scholarly activities on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, or dialect.

4. Individuals shall not misrepresent the credentials of aides, assistants, technicians, support personnel, students, research interns, Clinical Fellows, or any others under their supervision, and they shall inform those they serve professionally of the name, role, and professional credentials of persons providing services.

5. Individuals who hold the Certificate of Clinical Competence may delegate tasks related to the provision of clinical services to aides, assistants, technicians, support personnel, or any other persons only if those persons are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual.

6. Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to aides, assistants, technicians, support personnel, or any nonprofessionals over whom they have supervisory responsibility.

7. Individuals who hold the Certificate of Clinical Competence may delegate to students tasks related to the provision of clinical services that require the unique skills, knowledge, and judgment that are within the scope of practice of their profession only if those students are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual.

8. Individuals shall obtain informed consent from the persons they serve about the nature and possible risks and effects of services provided, technology employed, and products dispensed. This obligation also includes informing persons served about possible effects of not engaging in treatment or not following clinical recommendations. If diminished decision-making ability of persons served is suspected, individuals should seek appropriate authorization for services, such as authorization from a spouse, other family member, or legally authorized/appointed representative.

9. Individuals shall enroll and include persons as participants in research or teaching demonstrations only if participation is voluntary, without coercion, and with informed consent.

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10. Individuals shall accurately represent the intended purpose of a service, product, or research endeavor and shall abide by established guidelines for clinical practice and the responsible conduct of research.

11. Individuals who hold the Certificate of Clinical Competence shall evaluate the effectiveness of services provided, technology employed, and products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected.

12. Individuals may make a reasonable statement of prognosis, but they shall not guarantee—directly or by implication—the results of any treatment or procedure.

13. Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.

14. Individuals who hold the Certificate of Clinical Competence shall not provide clinical services solely by correspondence, but may provide services via telepractice consistent with professional standards and state and federal regulations.

15. Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law.

16. Individuals shall protect the confidentiality of any professional or personal information about persons served professionally or participants involved in research and scholarly activities and may disclose confidential information only when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law.

17. Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted.

18. Individuals whose professional practice is adversely affected by substance abuse, addiction, or other health-related conditions are impaired practitioners and shall seek professional assistance and, where appropriate, withdraw from the affected areas of practice.

19. Individuals who have knowledge that a colleague is unable to provide professional services with reasonable skill and safety shall report this information to the appropriate authority, internally if a mechanism exists and, otherwise, externally.

20. Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.

Principle of Ethics II

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

Rules of Ethics

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1. Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

2. Members who do not hold the Certificate of Clinical Competence may not engage in the provision of clinical services; however, individuals who are in the certification application process may engage in the provision of clinical services consistent with current local and state laws and regulations and with ASHA certification requirements.

3. Individuals who engage in research shall comply with all institutional, state, and federal regulations that address any aspects of research, including those that involve human participants and animals.

4. Individuals shall enhance and refine their professional competence and expertise through engagement in lifelong learning applicable to their professional activities and skills.

5. Individuals in administrative or supervisory roles shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member's certification status, competence, education, training, and experience.

6. Individuals in administrative or supervisory roles shall not require or permit their professional staff to provide services or conduct clinical activities that compromise the staff member's independent and objective professional judgment.

7. Individuals shall make use of technology and instrumentation consistent with accepted professional guidelines in their areas of practice. When such technology is not available, an appropriate referral may be made.

8. Individuals shall ensure that all technology and instrumentation used to provide services or to conduct research and scholarly activities are in proper working order and are properly calibrated.

Principle of Ethics III

Individuals shall honor their responsibility to the public when advocating for the unmet communication and swallowing needs of the public and shall provide accurate information involving any aspect of the professions.

Rules of Ethics

1. Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions.

2. Individuals shall avoid engaging in conflicts of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity.

3. Individuals shall not misrepresent research and scholarly activities, diagnostic information, services provided, results of services provided, products dispensed, or the effects of products dispensed.

4. Individuals shall not defraud through intent, ignorance, or negligence or engage in any scheme to defraud in connection with obtaining payment, reimbursement, or

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grants and contracts for services provided, research conducted, or products dispensed.

5. Individuals' statements to the public shall provide accurate and complete information about the nature and management of communication disorders, about the professions, about professional services, about products for sale, and about research and scholarly activities.

6. Individuals' statements to the public shall adhere to prevailing professional norms and shall not contain misrepresentations when advertising, announcing, and promoting their professional services and products and when reporting research results.

7. Individuals shall not knowingly make false financial or nonfinancial statements and shall complete all materials honestly and without omission.

Principle of Ethics IV

Individuals shall uphold the dignity and autonomy of the professions, maintain collaborative and harmonious interprofessional and intraprofessional relationships, and accept the professions' self-imposed standards.

Rules of Ethics

1. Individuals shall work collaboratively, when appropriate, with members of one's own profession and/or members of other professions to deliver the highest quality of care.

2. Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative mandate, referral source, or prescription prevents keeping the welfare of persons served paramount.

3. Individuals' statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations.

4. Individuals shall not engage in any form of conduct that adversely reflects on the professions or on the individual's fitness to serve persons professionally.

5. Individuals shall not engage in dishonesty, negligence, fraud, deceit, or misrepresentation.

6. Applicants for certification or membership, and individuals making disclosures, shall not knowingly make false statements and shall complete all application and disclosure materials honestly and without omission.

7. Individuals shall not engage in any form of harassment, power abuse, or sexual harassment.

8. Individuals shall not engage in sexual activities with individuals (other than a spouse or other individual with whom a prior consensual relationship exists) over whom they exercise professional authority or power, including persons receiving services, assistants, students, or research participants.

9. Individuals shall not knowingly allow anyone under their supervision to engage in any practice that violates the Code of Ethics.

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10. Individuals shall assign credit only to those who have contributed to a publication, presentation, process, or product. Credit shall be assigned in proportion to the contribution and only with the contributor's consent.

11. Individuals shall reference the source when using other persons' ideas, research, presentations, results, or products in written, oral, or any other media presentation or summary. To do otherwise constitutes plagiarism.

12. Individuals shall not discriminate in their relationships with colleagues, assistants, students, support personnel, and members of other professions and disciplines on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, dialect, or socioeconomic status.

13. Individuals with evidence that the Code of Ethics may have been violated have the responsibility to work collaboratively to resolve the situation where possible or to inform the Board of Ethics through its established procedures.

14. Individuals shall report members of other professions who they know have violated standards of care to the appropriate professional licensing authority or board, other professional regulatory body, or professional association when such violation compromises the welfare of persons served and/or research participants.

15. Individuals shall not file or encourage others to file complaints that disregard or ignore facts that would disprove the allegation; the Code of Ethics shall not be used for personal reprisal, as a means of addressing personal animosity, or as a vehicle for retaliation.

16. Individuals making and responding to complaints shall comply fully with the policies of the Board of Ethics in its consideration, adjudication, and resolution of complaints of alleged violations of the Code of Ethics.

17. Individuals involved in ethics complaints shall not knowingly make false statements of fact or withhold relevant facts necessary to fairly adjudicate the complaints.

18. Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.

19. Individuals who have been convicted; been found guilty; or entered a plea of guilty or nolo contendere to (1) any misdemeanor involving dishonesty, physical harm—or the threat of physical harm—to the person or property of another, or (2) any felony, shall self-report by notifying ASHA Standards and Ethics (see Terminology for mailing address) in writing within 30 days of the conviction, plea, or finding of guilt. Individuals shall also provide a certified copy of the conviction, plea, nolo contendere record, or docket entry to ASHA Standards and Ethics within 30 days of self-reporting.

20. Individuals who have been publicly sanctioned or denied a license or a professional credential by any professional association, professional licensing authority or board, or other professional regulatory body shall self-report by notifying ASHA Standards and Ethics (see Terminology for mailing address) in writing within 30 days of the final action or disposition. Individuals shall also provide a certified copy of the final action, sanction, or disposition to ASHA Standards and Ethics within 30 days of self-reporting.

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Section 1611 - Code of Ethics (Oklahoma Board of Examiners for Speech-Language Pathology and Audiology)

A. The Board of Examiners for Speech-Language Pathology and Audiology shall publish a code of ethics. The code shall take into account the professional character of speech-language and hearing services, and shall be designed to protect the interests of the client and the public.

B. In developing and revising the code of ethics, the Board shall hold hearings where interested persons may be heard on the subject. In addition, the Board will take into account the ethical standards promulgated by the American Speech-Language-Hearing Association.

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TITLE 690 - RULES OF THE BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY CHAPTER 15. PROFESSIONAL CODE OF ETHICS Section 690:15-1-1. Purpose and interpretation 690:15-1-2. Fundamental rules of ethical conduct 690:15-1-3. Principles of ethics 690:15-1-4. Ethical proscriptions 690:15-1-5. Matters of professional propriety 690:15-1-1. Purpose and interpretation The preservation of the highest standards of integrity and ethical principles is vital to all speech language pathologists and audiologists. This Code of Ethics is promulgated in an effort to stress the fundamental rules considered essential to this basic purpose. Any action that is in violation of the spirit and purpose of this code shall be considered unethical. Failure to specify any particular responsibility or practice in this Code of Ethics should not be construed as denial of the existence of other responsibilities or practices. 690:15-1-2. Fundamental rules The fundamental rules of ethical conduct are described in this Chapter in three categories: (1) Principles of Ethics, (2) Ethical Proscriptions, and (3) Matters of Professional Propriety. 690:15-1-3. Principles of ethics Six Principles serve as a basis for the ethical evaluation of professional conduct and form the underlying moral basis for the Code of Ethics. Individuals subscribing to this Code shall observe these principles as affirmative obligations under all conditions of professional activity. (1) Licensees shall hold paramount the welfare of persons served professionally. (A) Licensees shall use every resource available, including referral to other specialist as needed, to provide the best service possible. (B) Licensees shall fully inform persons served of the nature and possible effects of the services. (C) Licensees' fees shall be commensurate with services rendered. (D) Licensees shall provide appropriate access to records of persons served professionally. (E) Licensees shall take all reasonable precautions to avoid injuring persons in the delivery of professional services. (F) Licensees shall evaluate services rendered to determine effectiveness. (2) Licensees shall maintain high standards of professional competence. (A) Licensees engaging in clinical practice shall possess appropriate qualifications as defined in the Speech-Language Pathology and Audiology Licensing Act. 59 O.S. 1601, et. seq., as amended, and this Title. (B) Licensees shall continue their professional development throughout their careers. (C) Licensees shall identify competent, dependable referral sources for persons served professionally. (D) Licensees shall maintain adequate records of professional services rendered. (3) Licensees' statements to persons served professionally and to the public shall provide accurate information about the nature and management of communicative disorders and about the profession and services rendered by its practitioners. (4) Licensees shall maintain objectivity in all matters concerning the welfare of persons served professionally. Licensees shall observe the following standards:

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(A) Products associated with professional practice must be dispensed to the person served as a part of a program of comprehensive habilitative care. (B) Fees established for professional services must be independent of whether a product is dispensed. (C) Persons served must be provided freedom of choice for the source of services and products. (D) Price information about professional services rendered and products dispensed must be made available to the person served upon request and must include a complete schedule of fees and charges which schedule differentiates between fees for professional services and charges for products. (E) Products dispensed to the person served must be evaluated to determine effectiveness. (5) Licensees shall honor their responsibilities to the public, their profession, and their relationships with colleagues and members of allied professions. (6) Licensees shall uphold the dignity of the profession and its standards. (A) Licensees shall inform the Board of violations of this Code of Ethics. (B) Licensees shall cooperate fully with Board inquiries into matters of professional conduct related to this Code of Ethics. 690:15-1-4. Ethical proscriptions Ethical Proscriptions are formal statements of prohibitions that are derived from the Principles of Ethics. (1) The following proscriptions are derived from 690:15-l-3(1): (A) Licensees must not exploit persons in the delivery of professional services, including accepting persons for treatment when benefit cannot reasonably be expected or continuing treatment unnecessarily. (B) (B) Licensees must not guarantee the results of any therapeutic procedures, directly or by implication. A reasonable statement of prognosis may be made, but caution must be exercised not to mislead persons served professionally to expect results that cannot be predicted from sound evidence. (C) Licensees must not use persons for teaching or research in a manner that constitutes invasion of privacy or fails to afford informed free choice to participate. (D) Licensees must not provide clinical services except in a professional relationship. They must not evaluate or treat solely by correspondence or telepractice. This does not preclude follow-up correspondence with persons previously seen, or providing them with general information of an educational nature. (E) Licensees must not reveal to unauthorized persons any professional or personal information obtained from the person served professionally, unless required by law or unless necessary to protect the welfare of the person or the community. (F) Licensees must not discriminate in the delivery of professional services on any basis that is unjustifiable or irrelevant to the need for and potential benefit from such services, such as race, sex, religion or condition. (G) (G) Licensees must not charge for services not rendered. (H) (H) Licensees shall not violate any provisions of the Speech-Language Pathology and Audiology Licensing Act or Rules. (2) The following proscriptions are derived from 690:15-1-3(2): (A) Licensees must neither provide services nor supervision of services for which they have not been properly prepared, nor permit services to be provided by any of their staff who are not properly prepared. (B) Licensees must not provide clinical services by prescription of anyone who does not hold a license or its equivalent in the appropriate area.

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(C) Licensees must not offer clinical services by supportive personnel for whom they do not provide appropriate supervision and assume full responsibility. (D) Licensees must not require anyone under their supervision to engage in any practice that is a violation of the Code of Ethics. (3) The following proscriptions are derived from 690:15-1-3(3): (A) Licensees must not misrepresent their training or competence. Academic degrees, if listed, must be those awarded by a college or university listed in the Education Directory: Higher Education (published by the United States Department of Education). (B) Licensees' public statements providing information about professional services and products must not contain representations or claims that are false, deceptive or misleading. (C) Licensees must not use professional or commercial affiliations in any way that would mislead or limit services to persons served professionally. 690:15-1-5. Matters of professional propriety Matters of Professional Propriety represent guidelines of conduct designed to promote the public interest and thereby better inform the public and particularly persons in need of speech-language pathology and audiology services as to the availability and the rules regarding the delivery of those services. (1) Licensees should announce services in a manner consonant with highest professional standards in the community. (2) Licensees should not accept compensation for supervision or sponsorship from persons being supervised or sponsored. (3) Licensees should present products they have developed to their colleagues in a manner consonant with highest professional standards. (4) Licensees should seek to provide and expand services to persons with speech, language, and hearing handicaps as well as to assist in establishing high professional standards for such programs. (5) Licensees should educate the public about speech, language, and hearing processes, speech, language, and hearing problems, and matters related to professional competence. (6) Licensees should strive to increase knowledge within the profession and share research with colleagues. (7) Licensees should establish harmonious relations with colleagues and members of other professions, and endeavor to inform members of related professions of services provided by speech-language pathologists and audiologists, as well as seek information from them. (8) Licensees should assign credit to those who have contributed to a publication in proportion to their contribution.

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Standards and Implementation for the Certificate of Clinical Competence in Speech-Language Pathology

Effective Date: January 1, 2020

Introduction

The Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) is a semi-autonomous credentialing body of the American Speech-Language-Hearing Association (ASHA). The charges to the CFCC are to define the standards for clinical certification; to apply those standards in granting certification to individuals; to have final authority to withdraw certification in cases where certification has been granted on the basis of inaccurate information; and to administer the certification maintenance program.

A Practice and Curriculum Analysis of the Profession of Speech-Language Pathology was conducted in 2017 under the auspices of the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) and the CFCC. The survey analysis was reviewed by the CFCC, and the following standards were developed to better fit current practice models.

The 2020 Standards and Implementation Procedures for the Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) go into effect on January 1, 2020. View the SLP Standards Crosswalk [PDF] and consult Changes to Speech-Language Pathology Standards for more specific information on how the standards will change.

Terminology

Clinical educator: Refers to and may be used interchangeably with supervisor, clinical instructor, and preceptor

Individual: Denotes clients, patients, students, and other recipients of services provided by the speech-language pathologist.

Citation

Cite as: Council for Clinical Certification in Audiology and Speech-Language Pathology of the American Speech-Language-Hearing Association. (2018). 2020 Standards for the

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Certificate of Clinical Competence in Speech-Language Pathology. Retrieved from https://www.asha.org/certification/2020-SLP-Certification-Standards.

The Standards for the CCC-SLP are shown in bold. The CFCC implementation procedures follow each standard.

● Standard I—Degree ● Standard II—Education Program ● Standard III—Program of Study ● Standard IV—Knowledge Outcomes ● Standard V—Skills Outcomes ● Standard VI—Assessment ● Standard VII—Speech-Language Pathology Clinical Fellowship ● Standard VIII—Maintenance of Certification

Standard I: Degree

The applicant for certification (hereafter, “applicant”) must have a master's, doctoral, or other recognized post-baccalaureate degree.

Standard II: Education Program

All graduate coursework and graduate clinical experience required in speech-language pathology must have been initiated and completed in a speech-language pathology program accredited by the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA).

Implementation: The graduate program of study must be initiated and completed in a CAA-accredited program or a program with candidacy status for CAA accreditation. The applicant’s program director or official designee must complete and submit a program director verification form. Applicants must submit an official graduate transcript or a letter from the registrar that verifies the date on which the graduate degree was awarded. The official graduate transcript or letter from the registrar must be received by the ASHA National Office no later than one (1) year from the date on which the application was received. Verification of the applicant’s graduate degree is required before the CCC-SLP can be awarded.

Applicants educated outside the United States or its territories must submit documentation that coursework was completed in an institution of higher education that is regionally accredited or recognized by the appropriate regulatory authority for that country. In

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addition, applicants outside the United States or its territories must meet each of the standards that follow.

Standard III: Program of Study

The applicant must have completed a program of study (a minimum of 36 semester credit hours at the graduate level) that includes academic coursework and supervised clinical experience sufficient in depth and breadth to achieve the specified knowledge and skills outcomes stipulated in Standards IV-A through IV-G and Standards V-A through V-C.

Implementation: The minimum of 36 graduate semester credit hours must have been earned in a program that addresses the knowledge and skills pertinent to the ASHA Scope of Practice in Speech-Language Pathology .

Standard IV: Knowledge Outcomes

Standard IV-A

The applicant must have demonstrated knowledge of statistics as well as the biological, physical, and social/behavioral sciences.

Implementation: Coursework in statistics as well as in biological, physical, and social/behavioral sciences that is specifically related to communication sciences and disorders (CSD) may not be applied for certification purposes to this category unless the course fulfills a general the university requirement in the statistics, biology, physical science, or chemistry areas.

Acceptable courses in biological sciences should emphasize a content area related to human or animal sciences (e.g., biology, human anatomy and physiology, neuroanatomy and neurophysiology, human genetics, veterinary science). Chemistry and physics are important for the foundational understanding of the profession of speech-language pathology. For all applicants who apply beginning January 1, 2020, courses that meet the physical science requirement must be in physics or chemistry. Program directors must evaluate the course descriptions or syllabi of any courses completed prior to students entering their programs to determine if the content provides foundational knowledge in physics or chemistry. Acceptable courses in social/behavioral sciences should include psychology, sociology, anthropology, or public health. A stand-alone course in statistics is

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required. Coursework in research methodology in the absence of basic statistics cannot be used to fulfill this requirement.

Standard IV-B

The applicant must have demonstrated knowledge of basic human communication and swallowing processes, including the appropriate biological, neurological, acoustic, psychological, developmental, and linguistic and cultural bases. The applicant must have demonstrated the ability to integrate information pertaining to normal and abnormal human development across the life span.

Standard IV-C

The applicant must have demonstrated knowledge of communication and swallowing disorders and differences, including the appropriate etiologies, characteristics, and anatomical/physiological, acoustic, psychological, developmental, and linguistic and cultural correlates in the following areas:

● Speech sound production, to encompass articulation, motor planning and execution, phonology, and accent modification

● Fluency and fluency disorders ● Voice and resonance, including respiration and phonation ● Receptive and expressive language, including phonology, morphology, syntax,

semantics, pragmatics (language use and social aspects of communication), prelinguistic communication, paralinguistic communication (e.g., gestures, signs, body language), and literacy in speaking, listening, reading, and writing

● Hearing, including the impact on speech and language ● Swallowing/feeding, including (a) structure and function of orofacial myology

and (b) oral, pharyngeal, laryngeal, pulmonary, esophageal, gastrointestinal, and related functions across the life span

● Cognitive aspects of communication, including attention, memory, sequencing, problem solving, and executive functioning

● Social aspects of communication, including challenging behavior, ineffective social skills, and lack of communication opportunities

● Augmentative and alternative communication modalities

Implementation: It is expected that coursework addressing the professional knowledge specified in this standard will occur primarily at the graduate level.

Standard IV-D

For each of the areas specified in Standard IV-C, the applicant must have demonstrated current knowledge of the principles and methods of prevention, assessment, and intervention for persons with communication and swallowing

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disorders, including consideration of anatomical/physiological, psychological, developmental, and linguistic and cultural correlates.

Standard IV-E

The applicant must have demonstrated knowledge of standards of ethical conduct.

Implementation: The applicant must have demonstrated knowledge of the principles and rules of the current ASHA Code of Ethics .

Standard IV-F

The applicant must have demonstrated knowledge of processes used in research and of the integration of research principles into evidence-based clinical practice.

Implementation: The applicant must have demonstrated knowledge of the principles of basic and applied research and research design. In addition, the applicant must have demonstrated knowledge of how to access sources of research information and must have demonstrated the ability to relate research to clinical practice.

Standard IV-G

The applicant must have demonstrated knowledge of contemporary professional issues.

Implementation: The applicant must have demonstrated knowledge of professional issues that affect speech-language pathology. Issues include trends in professional practice,

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academic program accreditation standards, ASHA practice policies and guidelines, educational legal requirements or policies, and reimbursement procedures.

Standard IV-H

The applicant must have demonstrated knowledge of entry level and advanced certifications, licensure, and other relevant professional credentials, as well as local, state, and national regulations and policies relevant to professional practice.

Standard V: Skills Outcomes

Standard V-A

The applicant must have demonstrated skills in oral and written or other forms of communication sufficient for entry into professional practice.

Implementation: Applicants are eligible to apply for certification once they have completed all graduate-level academic coursework and clinical practicum and have been judged by the graduate program as having acquired all of the knowledge and skills mandated by the current standards.

The applicant must have demonstrated communication skills sufficient to achieve effective clinical and professional interaction with persons receiving services and relevant others. For oral communication, the applicant must have demonstrated speech and language skills in English, which, at a minimum, are consistent with ASHA's current position statement on students and professionals who speak English with accents and nonstandard dialects. In addition, the applicant must have demonstrated the ability to write and comprehend

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technical reports, diagnostic and treatment reports, treatment plans, and professional correspondence in English.

Standard V-B

The applicant must have completed a program of study that included experiences sufficient in breadth and depth to achieve the following skills outcomes:

1. Evaluation

a. Conduct screening and prevention procedures, including prevention activities.

b. Collect case history information and integrate information from clients/patients, family, caregivers, teachers, and relevant others, including other professionals.

c. Select and administer appropriate evaluation procedures, such as behavioral observations, nonstandardized and standardized tests, and instrumental procedures.

d. Adapt evaluation procedures to meet the needs of individuals receiving services.

e. Interpret, integrate, and synthesize all information to develop diagnoses and make appropriate recommendations for intervention.

f. Complete administrative and reporting functions necessary to support evaluation.

g. Refer clients/patients for appropriate services.

2. Intervention

a. Develop setting-appropriate intervention plans with measurable and achievable goals that meet clients’/patients’ needs. Collaborate with clients/patients and relevant others in the planning process.

b. Implement intervention plans that involve clients/patients and relevant others in the intervention process.

c. Select or develop and use appropriate materials and instrumentation for prevention and intervention.

d. Measure and evaluate clients’/patients’ performance and progress.

e. Modify intervention plans, strategies, materials, or instrumentation as appropriate to meet the needs of clients/patients.

f. Complete administrative and reporting functions necessary to support intervention.

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g. Identify and refer clients/patients for services, as appropriate.

3. Interaction and Personal Qualities

a. Communicate effectively, recognizing the needs, values, preferred mode of communication, and cultural/linguistic background of the individual(s) receiving services, family, caregivers, and relevant others.

b. Manage the care of individuals receiving services to ensure an interprofessional, team-based collaborative practice.

c. Provide counseling regarding communication and swallowing disorders to clients/patients, family, caregivers, and relevant others.

d. Adhere to the ASHA Code of Ethics, and behave professionally.

Implementation: The applicant must have acquired the skills listed in this standard and must have applied them across the nine major areas listed in Standard IV-C. These skills may be developed and demonstrated through direct clinical contact with individuals receiving services in clinical experiences, academic coursework, labs, simulations, and examinations, as well as through the completion of independent projects.

The applicant must have obtained a sufficient variety of supervised clinical experiences in different work settings and with different populations so that the applicant can demonstrate skills across the ASHA Scope of Practice in Speech-Language Pathology. Supervised clinical experience is defined as clinical services (i.e., assessment/diagnosis/evaluation, screening, treatment, report writing, family/client consultation, and/or counseling) related to the management of populations that fit within the ASHA Scope of Practice in Speech-Language Pathology .

These experiences allow students to:

● interpret, integrate, and synthesize core concepts and knowledge; ● demonstrate appropriate professional and clinical skills; and ● incorporate critical thinking and decision-making skills while engaged in

prevention, identification, evaluation, diagnosis, planning, implementation, and/or intervention.

Supervised clinical experiences should include interprofessional education and interprofessional collaborative practice, and should include experiences with related professionals that enhance the student’s knowledge and skills in an interdisciplinary, team-based, comprehensive service delivery model.

Clinical simulations (CS) may include the use of standardized patients and simulation technologies (e.g., standardized patients, virtual patients, digitized mannequins, immersive

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reality, task trainers, computer-based interactive).These supervised experiences can be synchronous simulations (real-time) or asynchronous (not concurrent in time) simulations.

Clinical educators of clinical experiences must hold current ASHA certification in the appropriate area of practice during the time of supervision. The supervised activities must be within the ASHAScope of Practice in Speech-Language Pathology in order to count toward the student’s ASHA certification requirements.

Standard V-C

The applicant must complete a minimum of 400 clock hours of supervised clinical experience in the practice of speech-language pathology. Twenty-five hours must be spent in guided clinical observation, and 375 hours must be spent in direct client/patient contact.

Implementation: Guided clinical observation hours generally precede direct contact with clients/patients. Examples of guided observations may include but are not limited to the following activities: debriefing of a video recording with a clinical educator who holds the CCC-SLP, discussion of therapy or evaluation procedures that had been observed, debriefings of observations that meet course requirements, or written records of the observations. It is important to confirm that there was communication between the clinical educator and observer, rather than passive experiences where the student views sessions and/or videos. It is encouraged that the student observes live and recorded sessions across settings with individuals receiving services with a variety of disorders and completes debriefing activities as described above.

The observation and direct client/patient contact hours must be within the ASHA Scope of Practice in Speech-Language Pathology and must be under the supervision of a qualified professional who holds a current ASHA certification in the appropriate practice area. Guided clinical supervision may occur simultaneously during the student’s observation or afterwards through review and approval of the student’s written reports or summaries. Students may use video recordings of client services for observation purposes.

Applicants should be assigned practicum only after they have acquired a base of knowledge sufficient to qualify for such experience. Only direct contact (e.g., the individual receiving services must be present) with the individual or the individual's family in assessment, intervention, and/or counseling can be counted toward practicum. When counting clinical practicum hours for purposes of ASHA certification, only the actual time spent in sessions can be counted, and the time spent cannot be rounded up to the nearest 15-minute interval.

Up to 20% (i.e., 75 hours) of direct contact hours may be obtained through CS methods. Only the time spent in active engagement with CS may be counted. CS may include the use of standardized patients and simulation technologies (e.g., standardized patients, virtual

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patients, digitized mannequins, immersive reality, task trainers, computer-based interactive). Debriefing activities may not be included as clinical clock hours.

Although several students may observe a clinical session at one time, clinical practicum hours should be assigned only to the student who provides direct services to the individual receiving services or the individual's family. Typically, only one student at a time should be working with a client in order to count the practicum hours. Several students working as a team may receive credit for the same session, depending on the specific responsibilities that each student is assigned when working directly with the individual receiving services. The applicant must maintain documentation of their time spent in supervised practicum, and this documentation must be verified by the program in accordance with Standards III and IV.

Standard V-D

At least 325 of the 400 clock hours of supervised clinical experience must be completed while the applicant is enrolled in graduate study in a program accredited in speech-language pathology by the CAA.

Implementation: A minimum of 325 clock hours of supervised clinical practicum must be completed while the student is enrolled in the graduate program. At the discretion of the graduate program, hours obtained at the undergraduate level may be used to satisfy the remainder of the requirement.

Standard V-E

Supervision of students must be provided by a clinical educator who holds ASHA certification in the appropriate profession, who has the equivalent of a minimum of 9 months of full-time clinical experience, and who has completed a minimum of 2 hours of professional development in clinical instruction/supervision after being awarded ASHA certification.

The amount of direct supervision must be commensurate with the student’s knowledge, skills, and experience; must not be less than 25% of the student's total contact with each client/patient; and must take place periodically throughout the practicum. Supervision must be sufficient to ensure the welfare of the individual receiving services.

Implementation: Effective January 1, 2020, supervisors for ASHA certification must complete 2 hours of professional development/continuing education in clinical instruction/supervision. The professional development/continuing education must be completed after being awarded ASHA certification and prior to the supervision of a student. Direct supervision must be in real time. A clinical educator must be available and on site to consult with a student who is providing clinical services to the clinical educator's client.

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Supervision of clinical practicum is intended to provide guidance and feedback and to facilitate the student’s acquisition of essential clinical skills.

In the case of CS, asynchronous supervision must include debriefing activities that are commensurate with a minimum of 25% of the clock hours earned for each simulated individual receiving services.

Standard V-F

Supervised practicum must include experience with individuals across the life span and from culturally/linguistically diverse backgrounds. Practicum must include experience with individuals with various types and severities of communication and/or related disorders, differences, and disabilities.

Implementation: The applicant must demonstrate direct clinical experiences with individuals in both assessment and intervention across the lifespan from the range of disorders and differences named in Standard IV-C.

Standard VI: Assessment

The applicant must have passed the national examination adopted by ASHA for purposes of certification in speech-language pathology.

Implementation: Results of the Praxis® Examination in Speech-Language Pathology must be submitted directly to ASHA from the Educational Testing Service (ETS). The certification standards require that a passing exam score be earned no earlier than 5 years prior to the submission of the application and no later than 2 years following receipt of the application. If the exam is not successfully passed and reported within the 2-year application period, the applicant's certification file will be closed. If the exam is passed or reported at a later date, then the applicant will be required to reapply for certification under the standards in effect at that time.

Standard VII: Speech-Language Pathology Clinical

Fellowship

The applicant must successfully complete a Speech-Language Pathology Clinical Fellowship (CF).

Implementation: The CF experience may be initiated only after completion of all graduate credit hours, academic coursework, and clinical experiences required to meet the knowledge and skills delineated in Standards IV and V. The CF experience must be initiated within 24 months of the date on which the application for certification is received. Once the CF has been initiated, it must be completed within 48 months of the initiation date. For

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applicants completing multiple CFs, all CF experiences related to the application must be completed within 48 months of the date on which the first CF was initiated. Applications will be closed for CFs that are not completed within the 48-month timeframe or that are not submitted to ASHA within 90 days after the 48-month timeframe. The Clinical Fellow will be required to reapply for certification and must meet the standards in effect at the time of re-application. CF experiences more than 5 years old at the time of application will not be accepted.

The CF must be completed under the mentorship of a clinician who held the CCC-SLP throughout the duration of the fellowship and must meet the qualifications described in Standard VII-B. It is the Clinical Fellow’s responsibility to identify a CF mentor who meets ASHA’s certification standards. Should the certification status of the mentoring SLP change during the CF experience, the Clinical Fellow will be awarded credit only for that portion of time during which the mentoring SLP held certification. It is incumbent upon the Clinical Fellow to verify the mentoring SLP’s status periodically throughout the CF experience. Family members or individuals related in any way to the Clinical Fellow may not serve as mentoring SLPs to that Clinical Fellow.

Standard VII-A: Clinical Fellowship Experience

The CF must consist of clinical service activities that foster the continued growth and integration of knowledge, skills, and tasks of clinical practice in speech-language pathology consistent with ASHA’s current Scope of Practice in Speech-Language Pathology. The CF must consist of no less than 36 weeks of full-time professional experience or its part-time equivalent.

Implementation: At least 80% of the Clinical Fellow’s major responsibilities during the CF experience must be in direct, in-person client/patient contact (e.g., assessment, diagnosis, evaluation, screening, treatment, clinical research activities, family/client consultations, recordkeeping, report writing, and/or counseling) related to the management process for individuals who exhibit communication and/or swallowing disabilities.

Full-time professional experience is defined as 35 hours per week, culminating in a minimum of 1,260 hours. Part-time experience should be at least 5 hours per week; anything less than that will not meet the CF requirement and may not be counted toward completion of the experience. Similarly, work in excess of 35 hours per week cannot be used to shorten the CF to less than 36 weeks.

Standard VII-B: Clinical Fellowship Mentorship

The Clinical Fellow must receive ongoing mentoring and formal evaluations by the CF mentor. Mentorship must be provided by a clinician who holds the CCC-SLP, who has the equivalent of a minimum of 9 months of full-time clinical experience, and

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who has completed a minimum of 2 hours of professional development/continuing education in clinical instruction/supervision after being awarded the CCC-SLP.

Implementation: Effective January 1, 2020, CF mentors for ASHA certification must complete 2 hours of professional development/continuing education in clinical instruction/supervision after being awarded the CCC-SLP and prior to mentoring the Clinical Fellow.

Direct observation must be in real time. A mentor must be available to consult with the Clinical Fellow who is providing clinical services. Direct observation of clinical practicum is intended to provide guidance and feedback and to facilitate the Clinical Fellow’s independent use of essential clinical skills

Mentoring must include on-site, in-person observations and other monitoring activities, which may be executed by correspondence, review of video and/or audio recordings, evaluation of written reports, telephone conferences with the Clinical Fellow, or evaluations by professional colleagues with whom the Clinical Fellow works. The CF mentor and the Clinical Fellow must participate in regularly scheduled formal evaluations of the Clinical Fellow’s progress during the CF experience. The Clinical Fellow must receive ongoing mentoring and formal evaluations by the CF mentor.

The amount of direct supervision provided by the CF mentor must be commensurate with the Clinical Fellow’s knowledge, skills, and experience, and must not be less than the minimum required direct contact hours. Supervision must be sufficient to ensure the welfare of the individual(s) receiving services.

The mentoring SLP must engage in no fewer than 36 supervisory activities during the CF experience and must include 18 on-site observations of direct client contact at the Clinical Fellow’s work site (1 hour = 1 on-site observation; a maximum of six on-site observations may be accrued in 1 day). At least six on-site observations must be conducted during each third of the CF experience. On-site observations must consist of the Clinical Fellow engaging in screening, evaluation, assessment, and/or habilitation/rehabilitation activities. Mentoring must include on-site, in-person observations; however, the use of real-time, interactive video and audio conferencing technology may be permitted as a form of observation, for which pre-approval must be obtained

Additionally, supervision must include 18 other monitoring activities. Other monitoring activities are defined as the evaluation of reports written by the Clinical Fellow, conferences between the CF mentor and the Clinical Fellow, discussions with professional colleagues of the Clinical Fellow, and so forth, and may be executed by correspondence, telephone, or reviewing of video and/or audio tapes. At least six other monitoring activities must be conducted during each third of the CF experience.

If the Clinical Fellow and their CF mentor want to use supervisory mechanisms other than those outlined above, they may submit a written request to the CFCC prior to initiating the CF. Written requests may be emailed to cfcc@asha.org or mailed to: CFCC, c/o ASHA Certification, 2200 Research Blvd. #313, Rockville, MD 20850. Requests must include the

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reason for the alternative supervision and a detailed description of the supervision that would be provided (i.e., type, length, frequency, etc.), and the request must be co-signed by both the Clinical Fellow and the CF mentor. On a case-by-case basis, the CFCC will review the circumstances and may or may not approve the supervisory process to be conducted in other ways. Additional information may be requested by the CFCC prior to approving any request.

Standard VII-C: Clinical Fellowship Outcomes

The Clinical Fellow must demonstrate knowledge and skills consistent with the ability to practice independently.

Implementation: At the completion of the CF experience, the applicant must have acquired and demonstrated the ability to:

● integrate and apply theoretical knowledge; ● evaluate their strengths and identify their limitations; ● refine clinical skills within the Scope of Practice in Speech-Language Pathology; and ● apply the ASHA Code of Ethics to independent professional practice.

In addition, upon completion of the CF, the applicant must demonstrate the ability to perform clinical activities accurately, consistently, and independently and to seek guidance as necessary.

The CF mentor must document and verify a Clinical Fellow's clinical skills using the Clinical Fellowship Report and Rating Form, which includes the Clinical Fellowship Skills Inventory (CFSI), as soon as the Clinical Fellow successfully completes the CF experience. This report must be signed by both the Clinical Fellow and CF mentor.

Standard VIII: Maintenance of Certification

Certificate holders must demonstrate continued professional development for maintenance of the CCC-SLP.

Implementation: Clinicians who hold the CCC-SLP must accumulate and report 30 Certification Maintenance Hours (CMHs) (or 3.0 ASHA continuing education units [CEUs]) of professional development, which must include a minimum of 1 CMH (or 0.1 ASHA CEU) in ethics during every 3-year certification maintenance interval beginning with the 2020–2022 maintenance interval.

Intervals are continuous and begin January 1 of the year following the initial awarding of certification or the reinstatement of certification. Random audits of compliance are conducted.

Accrual of professional development hours, adherence to the ASHA Code of Ethics , submission of certification maintenance compliance documentation, and payment of

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annual membership dues and/or certification fees are required for maintenance of certification.

If maintenance of certification is not accomplished within the 3-year interval, then certification will expire. Those who wish to regain certification must submit a reinstatement application and meet the standards in effect at the time the reinstatement application is submitted.

Procedures for Complaints Against Graduate Education Programs

A complaint about any accredited program or program in Candidacy status may be submitted by any student, instructional staff member, speech-language pathologist, audiologist, and/or member of the public.

Criteria for Complaints Against Graduate Education Programs

Complaints about programs must: (a) be against an accredited education program or program in Candidacy status in speech-language pathology and/or audiology, (b) relate to the standards for accreditation of education programs in audiology and speech language pathology, and (c) include verification, if the complaint is from a student or faculty/instructional staff member, that the complainant exhausted all institutional grievance and review mechanisms before submitting a complaint to the CAA.

All complaints must be signed and submitted in writing to the Chair, Council on Academic Accreditation in Audiology and Speech-Language Pathology, American Speech Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852. The complaint must clearly describe the specific nature of the complaint and the relationship of the complaint to the accreditation standards, and provide supporting data for the charge. The complainant's burden of proof is a preponderance or greater weight of the evidence. Complaints will not be accepted by email or facsimile.

Determination of Jurisdiction

Within 15 days of receipt of the complaint, Accreditation Office staff will acknowledge receipt of the complaint and will forward a redacted copy of the complaint to the Executive Committee of the CAA. The original letter of complaint is placed in a Accreditation Office file separate from the program's accreditation file. The Executive Committee determines whether the complaint meets the above-specified criteria. If the Executive Committee of the CAA makes the determination that the complaint does not meet the above-listed criteria, the complainant is informed within 30 days of the letter transmitting the complaint to the EC that the CAA will not review the complaint.

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Evaluation of Complaint

If the Executive Committee of the CAA determines that the complaint satisfies the above-listed criteria, the CAA will evaluate the complaint.

The chair of the CAA informs the complainant within 30 days of the letter transmitting the complaint to the chair that the Council will proceed with an evaluation. Because it may be necessary to reveal the identity of the complainant to the affected program or to other potential sources of relevant information, the complainant will be required to sign a waiver of confidentiality within 30 days of the letter indicating that the CAA will proceed with its evaluation. The complainant is given the opportunity to withdraw the complaint during that time. If the complainant does not wish to pursue the matter, the investigation is concluded. If the complainant does not wish to withdraw the complaint, the complainant is asked to keep the initiation of an investigation confidential.

Within 15 days of receipt of the waiver of confidentiality, the chair of the CAA notifies the program director and the institution's president or president's designee by certified return receipt mail that a complaint has been registered against the program. The notification includes a redacted copy of the complaint without revealing the identity of the complainant. The program's director and the institution's president or president's designee are requested to provide complete responsive information and supporting documentation that they consider relevant to the complaint within 45 days of the date of the notification letter.

Within 15 days of receipt of the program's response to the complaint, the chair of the CAA forwards the complaint and the program's response to the complaint to the CAA. The materials are redacted and the identity of the complainant and the program under investigation is not revealed to the members of the CAA or to recipients of requests for information, unless a majority of CAA members consider such disclosure necessary for the proper investigation of the complaint. If the majority of Council members conclude that individuals other than the complainant, the program director, and the institution's president or president's designee may have information relevant to the complaint, the chair of the CAA requests such information.

After reviewing all relevant information, the CAA determines the course of action within 30 days. Such actions include, but are not limited to the following:

● Dismissal of the complaint; ● Recommending changes in the program within a specified period of time and as

they relate to standards (except for those areas that are solely within the purview of the institution);

● Continuing the investigation through an on site visit to the program; ● Placing the program on probation; ● Withholding/withdrawing accreditation.

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If the CAA determines that a site visit is necessary, the program director and the institution's president or president's designee are notified, and a date for the site visit is expeditiously scheduled. The program is responsible for expenses of the site visit. The site visit team is selected from the current roster of CAA site visitors. During the site visit, emphasis is given only to those standards with which the program is allegedly not in compliance. The site visit team submits a written report to the CAA no later than 30 days following the site visit. As with all other site visits, only the observations of the site visitors are reported; site visitors do not make accreditation recommendations. The CAA forwards the report to the program director and the institution's president or president's designee within 15 days. The program or institution should provide a written response to the chair of the CAA within 30 days of the date on which the report is postmarked to the program director and the president or president's designee. The purpose of the response is to verify the accuracy of the site visit report.

The CAA reviews all evidence before it, including the site visit report and the program's response to the report, and takes one of the following actions within 21 days:

● Dismisses the complaint; ● Recommends modifications of the program within a specified period of time (except

for those areas that are solely within the purview of the institution); ● Places the program on probation; ● Withholds/withdraws accreditation.

If the CAA withholds/withdraws accreditation, the program director and the institution's president or president's designee are informed within 15 days of the CAA decision that accreditation has been withheld/withdrawn. Notification also includes justification for the decision, and informs the program of its option to request Further Consideration. Further consideration is the mechanism whereby the program can present documentary evidence of compliance with the appropriate standards and ask the CAA to reevaluate its decision to withhold/withdraw accreditation.

If the program does not exercise its Further Consideration option, the CAA's decision to withhold/withdraw accreditation is final and no further appeal may be taken. If accreditation is withheld/withdrawn, the chair of the CAA notifies the Secretary of the U.S. Department of Education at the same time that it notifies the program of the decision.

If the program chooses to request Further Consideration, the CAA must receive the request within 30 days from the date of the notification letter. With the request for Further Consideration, the program must submit additional written documentation to justify why accreditation should not be withheld/withdrawn. A hearing with the CAA is not provided for Further Consideration requests. The CAA will evaluate the request for Further Consideration and take one of the following actions within 30 days:

● Recommends modifications of the program within a specified period of time (except for those areas that are solely within the purview of the institution);

● Places the program on probation;

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● Withholds/withdraws accreditation.

Within 15 days of its decision the CAA notifies the program and the complainant of its decision.

If the CAA decision after Further Consideration is to withhold/withdraw accreditation, the program may appeal the decision in accord with the Appeal Procedures described in Chapter VI of this manual.

Summary of Timelines

The following summarizes the timelines in the complaint process, beginning from the date a complaint is received.

● Complaint is acknowledged within 15 days of receipt and forwarded to CAA Executive Committee (EC)

● If EC determines that complaint does not meet criteria for complaints, complainant is informed within 30 days that CAA will not review

● If EC determines that complaint meets criteria, complainant is informed within 30 days of the determination that CAA will proceed with evaluation

● Complainant is given 30 days to sign waiver of confidentiality or withdraw the complaint

● Within 15 days of receipt of waiver of confidentiality, the complaint is sent to the program for response within 45 days

● Within 15 days of receipt of program's response, Chair forwards complaint and program response to CAA for review

● Within 30 days, CAA determines course of action ● If CAA determines that a site visit is necessary, it is scheduled and site visit team

submits report to CAA within 30 days of visit ● Site visit report is forwarded to program for response within 30 days ● CAA takes action within 21 days of program response ● If CAA withholds or withdraws accreditation, program is notified within 15 days of

CAA decision ● If program does not request Further Consideration, decision is final and CAA notifies

Secretary of U.S. Department of Education; if program requests Further Consideration, CAA must receive within 30 days from notification and takes action within thirty 30 days

● CAA informs program and complainant within 15 days of decision

(Procedures for Complaints Against Graduate Education Programs. Retrieved March 24, 2006. from http://www.asha.org/about/credentialing/accreditation/accredmanual/section8.htm#complaint1)

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NORTHEASTERN STATE UNIVERSITY

SPEECH-LANGUAGE PATHOLOGY PROGRAM PROFESSIONAL HABITS INVENTORY

Student:_____________________________ Evaluator(s):____________________________ Circle one: Jr Sr Grad 1 Grad 2 Leveling Circle one: Fall Spring Summer Year: Check one: [ ] Formative [ ] Summative Check one: [ ] Overall [ ] Course specific -- Indicate course # Directions: Circle a number (1-5) indicating student performance in each area or check appropriate column if there was no opportunity to observe.

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No

opportunity to observe

UNACCEPTABLE PROGRESSING TARGET

Punctuality/Organization

Is frequently absent Is seldom absent from class

_______ 1 2 3 4 5 Arrives after class has begun or

leaves early Arrives to class on time/attends

entire class _______ 1 2 3 4 5 Assignments are turned in late Submits assignments in a timely

manner _______ 1 2 3 4 5 Assignments lack organization and

are asked to be redone Assignments are neat, organized

and reflect professionalism _______ 1 2 3 4 5

Confidentiality Inappropriately shares knowledge of faculty, staff and/or student issues with others

Is careful and discrete with information regarding faculty,

staff and/or student issues

_______ 1 2 3 4 5

Inappropriately shares knowledge of clinical situations or client information with others

Is careful and discrete with information regarding clinical

situations and client information _______ 1 5

Attitude/Initiative Demonstrates a negative attitude toward program or profession

Demonstrates a positive attitude and enthusiasm for program &

profession _______ 1 2 3 4 5

Unwilling to participate in clinical activities

Willingly participates in clinic activities

_______ 1 2 3 4 5

Flexibility Unable or unwilling to adjust to new/different work settings

Demonstrates flexibility and willingness to adjust to

new/different work settings _______ 1 2 3 4 5

Reacts with anger, denial or ignores constructive criticism

Accepts constructive criticism in a positive manner

_______ 1 2 3 4 5

Demonstrates reluctance to rethink preconceived ideas/concepts

Is willing to consider alternative options

_______ 1 2 3 4 5

Does not work in a cooperative and positive manner

Works with others in a cooperative and positive manner

_______ 1 2 3 4 5

Interactions with diverse populations

Makes inappropriate comments about diverse population

Shows respect for individuals of diverse population

_______ 1 2 3 4 5

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Appropriate attire Attire is inappropriate for specific setting

Attire is appropriate for specific setting

_______ 1 2 3 4 5

No opportunity to observe

UNACCEPTABLE PROGRESSING TARGET

Verbal communication Verbal communication reflects inappropriate grammar, vocabulary and pronunciation.

Verbal communication reflects proper grammar, vocabulary and

pronunciation. _______ 1 2 3 4 5

Verbally communicates in an illogical, unorganized manner

Verbally communicates in a logical, organized manner

_______ 1 2 3 4 5

Written communication

Written communication reflects inappropriate spelling, grammar and punctuation.

Written communication reflects appropriate spelling, grammar

and punctuation _______ 1 2 3 4 5

Writes in an illogical, unorganized manner

Writes in a logical, organized manner

_______ 1 2 3 4 5

Professional involvement

Does not belong to, attend, or participate in professional association(s)

Belongs to, attends, participates in professional association(s)

_______ 1 2 3 4 5

Does not read and review professional literature

Read and reviews professional literature

_______ 1 2 3 4 5

Professional ethics Uses sarcasm or disparaging remarks to ridicule or embarrass students, clients or faculty

Takes proper care to protect students from embarrassment or

ridicule _______ 1 2 3 4 5

Makes false or misleading statements regarding professional competencies and/or qualifications

Accurately represents his/her professional competencies

and/or qualifications _______ 1 2 3 4 5

Makes false or malicious statements about program, faculty or other students

Does not make false or malicious statements about program,

faculty or other students _______ 1 2 3 4 5

Inappropriately represents the work of others as their own (plagiarism)

Makes appropriate references to the work and/or ideas of others

_______ 1 2 3 4 5

Does not demonstrate compliance with ASHA code of ethics/OBESPA code of ethics

Demonstrates knowledge, understanding and compliance

with ASHA code of ethics/OBESPA code of ethics

1 2 3 4 5

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Academics/Clinical Routinely misses examinations Present & prepared for examinations

_______ 1 2 3 4 5

Does not read textbooks/articles assigned

Reads and discusses chapters in textbooks and articles assigned

_______ 1 2 3 4 5

Does not remember information from previous courses and class sessions

Applies information from previous courses and class

sessions _______ 1 2 3 4 5

Does not engage in class discussions Engages in class discussions

_______ 1 2 3 4 5

Does not seek additional information or ask questions

Seeks additional

information and/or asks questions

_______ 1 2 3 4 5

No

opportunity to observe

UNACCEPTABLE PROGRESSING TARGET

Academics/Clinical continued

Asks inappropriate questions in class/clinic

Asks relevant questions in class/clinic

_______ 1 2 3 4 5

Does not apply information from readings or courses clinically

Uses evidence base for clinical decisions

_______ 1 2 3 4 5

Unprepared for clinical assignments

Prepared for clinical assignments

_______ 1 2 3 4 5

Typical clinical performance Typical clinical performance 1= D or F 2=C 4=B 5=A

_______ Typical academic performance Typical academic performance 1= D or F 2=C 4=B 5=A

Summative only

Total Points from all boxes on the Professional Habits Inventory __________

Overall Rating Needs improvement Marginally professional

Demonstrating traits of a professional

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1 2 3 4 5

Comments: Student Signature Date Evaluator Signature Date

CALIPSO INFORMATION: You will log your daily clock hours into CALIPSO, this is an electronic database designed to keep track of your clinical practicum experiences. There will be a fee to sign up, but not to register. So that means you can register within those 40 days without paying the fee.

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The clinic director will send you an invite to this database. Once that invite is sent, you will receive an email with the following information. At the end of the email, there will be a pin provided just for you. You use that pin to complete the registration process. Once you receive your registration email, you will have 40 days to complete the registration process. Below is the email that you will receive: Student- As a Communication Sciences and Disorders student of Northeastern State University (OK), you have been asked to register for an account at Calipsoclient.com. If you are not a student enrolled in the Communication Sciences and Disorders Program, please reply to this e-mail immediately. Step One: * Begin registration by going to https://www.calipsoclient.com/nsuok/students/register * Complete the requested information, being sure to enter your "school" email address EXACTLY as it appears in the recipient field of this registration email. * Click "Register Account." Please note: PIN numbers are valid for 40 days. Contact your Coordinator for a new PIN if 40 days has elapsed since receiving this registration e-mail. Step Two: * After successful registration, login to CALIPSO ( https://www.calipsoclient.com/nsuok/ ) using your school email and password that you created for yourself in Step One. * Upon logging in for the first time, you will be prompted to pay the student fee (if applicable) and to provide consent for the release of information to clinical practicum sites. If you have questions, please contact your Coordinator at Northeastern State University (OK) Your registration PIN is ___________” Within that email, you will also receive a word document just like the one provided below that provides instructions and information for navigating CALIPSO. ● Before registering, have available the PIN provided by your Clinical Coordinator via e-mail.

Step 1: Register as a Student User on CALIPSO

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● Go to https://www.calipsoclient.com/● Click on the “Student” registration link located below the login button.● Complete the requested information, being sure to enter your “school” e-mail address, and

record your password in a secure location. Click “Register Account.”● Please note: PIN numbers are valid for 40 days. Contact your Clinical Coordinator for a new

PIN if 40 days has lapsed since receiving the registration e-mail.

● To login, go to https://www.calipsoclient.com/ and login to CALIPSO using your school e-mail and password that you created for yourself during the registration process (step one.)

● Upon logging in for the first time, you will be prompted to pay the student fee and to provide consent for the release of information to clinical practicum sites.

● Click on “Student Information”● Click on “Contact Info” and then “Edit” for each corresponding address.● Enter your local, permanent, and emergency contact info. Enter “rotation” contact info when on

externships. Return to this link to update as necessary.● Click “Home” located within the blue stripe to return to the home page.

● Before each semester, click on “Student Information” and then “Compliance/Immunizations” toview a record of compliance and immunization records.

● Missing or expired records are highlighted in red.● To create a document to save and/or print, click “PDF” located within the blue stripe.● An electronic file of the original documents can be accessed, if uploaded by the Clinical

Coordinator, by clicking “Files” located within the blue stripe.● Click “Home” located within the blue stripe to return to the home page.

● The file management feature allows you to upload any type of file (e.g. Word, PDF, JPEG,audio/video) to share with your clinical supervisor or clinical administrator.

● Click on “Student Information” and then “Clinical Placement” to upload your own file and/orview a file uploaded by your supervisor or clinical administrator.

Step 2: Login to CALIPSO

Step 3: Enter Contact Information

Step 4: View Immunization and Compliance Records

Step 5: View/Upload Clinical Placement Files

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● First, select a folder by clicking on the folder name or create a new folder or subfolder. To create a new folder or subfolder, type in desired folder name in the "Add folder" field and press "create."

● Upload a file by pressing the “Browse” button, selecting a file, completing the requested fields, and clicking "upload." The upload fields will display if you have selected an unrestricted folder. Set the file permission by choosing “public” for supervisor and clinical administrator access or “private” for clinical administrator access only.

● Move files by dragging and dropping from one folder to another. ● Rename folders by clicking the "rename" link to the right of the folder name. ● Delete files by clicking the “delete” button next to the file name. Delete folders by

deleting all files from the folder. Once all the files within the folder have been deleted, a “delete” link will appear to the right of the folder name.

● Click on the “Clockhours” link located on the lobby page or the “Student Information”

link then “Clockhours.” Click on the “Daily clockhours” link located within the blue stripe. ● Click on the “Add new daily clockhour” link. ● Complete the requested information and click “save.” ● Record clock hours and click “save” located at the bottom of the screen. You will receive

a “Clockhour saved” message. To add clock hours for a *different* supervisor, clinical setting, or semester: ● Repeat above steps to enter additional clock hours gained under a different supervisor, clinical setting, or semester. To add additional clock hours to the *same* record: ● Click on the “Daily clockhours” link located within the blue stripe. ● Select the record you wish to view (posted by supervisor, semester, course, and setting) from the drop-down menu and click “Show.” ● Click the “Copy” button located next to the date of a previous entry. ● Record the new clock hours (changing the date if necessary) and click “save” located at the bottom of the screen. You will receive a “Clockhour saved” message.

● To view/edit daily clock hours, click on the “Daily clockhours” link located within the blue stripe.

● Select the record you wish to view (posted by supervisor, semester, course, and setting) from the drop-down menu and click “Show.”

● Select the desired entry by clicking on the link displaying the entry date located along the top of the chart. Make desired changes and click save.

● Please note: Supervisors are not notified and are not required to approve daily clock hour submissions.

Step 6a: Enter Daily Clock Hours

Step 6b: Submit Clock Hours for Supervisor Approval

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● Click on the “Daily clockhours” link located within the blue stripe. ● Select the record you wish to view (posted by supervisor, semester, and course) from

the drop-down menu and click “Show.” ● Check the box (located beside the entry date) for all dates you wish to submit for

approval then click “Submit selected clockhours for supervisor approval.” Clock hours logged for the dates selected will be consolidated into one record for supervisor approval. The designated supervisor will receive an automatically generated e-mail requesting approval of the clock hour record.

● Please note: Daily entries cannot be edited once approved. However, if you delete the entry from the “Clockhour list” link prior to approval, daily hours may be resubmitted.

● View consolidated clock hour entries by clicking “Clockhours list” located within the blue stripe.

● Click on “Student Information” and then “Evaluations.” ● As clinical performance evaluations are completed on you by your supervisors, the evaluations

will automatically post to this link. ● View a desired evaluation by clicking on the “current evaluation” link highlighted in blue. ● Click on “Student Information” and then “Cumulative evaluation” to view a summary of your

clinical competency across the 9 disorder areas. ● Upon graduation, you must demonstrate competency for all clinical competencies listed on the

form. ● Please make note of any areas of deficiency which are highlighted in orange.

● Click on “Student Information” and then “Performance summary” to view a summary of your

clinical performance across all clinical courses to date.

Step 7: View Clinical Performance Evaluations

Step 8: View Cumulative Evaluation

Step 9: View Performance Summary

Step 10: View My Checklist

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● Click on “Student Information” and then “My Checklist” to view your progress in meeting the clinical requirements for graduation.

● Upon graduation, all requirements should have been met, represented with a green check mark

● At the completion of each clinical course or as directed by your Clinical Coordinator, complete a

self-evaluation. ● From the lobby page, click on the “Self-evaluations” link. ● Click on “New self-evaluation.” ● Complete required fields designated with an asterisk and press “save.” ● Continue completing self-evaluation by scoring all applicable skills across the Big 9 using the

provided scoring method and saving frequently to avoid loss of data. ● Once the evaluation is complete, check the “final submission” box and click “save.” ● Receive message stating “evaluation recorded.” ● Please note: you may edit and save the evaluation as often as you wish until the final

submission box is checked. Once the final submission box is checked and the evaluation saved, the status will change from “in progress” to “final”.

● To view the evaluation, click “Evaluations list” located within the blue stripe. ● At the completion of each clinical course or as directed by your Clinical Coordinator, complete

feedback for each clinical supervisor. ● From the lobby page, click “Supervisor feedback forms.” ● Click “New supervisor feedback.” ● Complete form and click “Submit feedback.” ● Your completed feedback form will be posted for Clinical Coordinator approval. Once

approved, feedback will be posted for the clinical supervisor to view. Until approved, the feedback may be edited by clicking on “View/edit.”

● The “Site Information Forms” link located on the lobby page displays pertinent information on

the sites/facilities that your school affiliates with for clinical placements. ● To view available information, identify the desired site and click “View” located in the fifth

column under submitted. ● Please note: “In progress” forms are not accessible to students; only “submitted” forms are

accessible to students.

Save this site to your favorites on your computer, you will use it often.

Step 11: Complete Self-Evaluation

Step 12: Complete Supervisor Feedback Form

Step 13: View Site Information Forms

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Login link for NSU students: https://www.calipsoclient.com/nsuok/account/login Below is what the login page will look like:

NORTHEASTERN STATE UNIVERSITY Speech-Language Pathology Clinical Practicum

Basic Competence Checklist

Student Clinician: _____________________________________________________________________________

Practicum Start Date: ___________________________ Completion Verified: ______________________

Clinic Director: ___________________________________________Date: ________________________________ In order to complete the requirements for clinical practicum in Speech-Language Pathology, the following competencies must be demonstrated. Items which are preceded with an (*) are REQUIRED.

Assessment of Performance Scale

74

0 Absent Student has not yet performed target skill or has many errors in the

performance

1 Minimally Adequate Student performs target skill with minimal errors and difficulties and requires continued assistance from supervisor/teacher to complete the skill

2 Adequate Student performs target skill with no errors or difficulties and moderate assistance from supervisor/teacher

3 Exceeds Adequate Student performs target skill effectively and efficiently with minimal assistance from teacher/supervisor

4 Far Exceed Adequate Student performs target skill effectively and efficiently without assistance from teacher/supervisor

EVALUATION

Articulation: Demonstrate the ability to administer, score and interpret at least 2 of the following Evaluation Name Date Supervisor Signature Rating

a. * lation Goldman Fristoe Test of Articulation (GFTA)

b. Photo Articulation Test (PAT)

c. Fisher-Logemann

d. Comp Comprehensive Assessment of

Articulation and Phonology (CAAP)

e. Arizona Articulation Rating Scale (AAPS)

f. Other:

g. * Oral Peripheral Examination

h. *

Determine Stimulability of Error

Phonemes

i.

Determine Intelligibility Levels for

Single Words/Connected

Speech

j.

Assign Appropriate Severity Levels

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k.

Determine Appropriate Goals

l.

Tongue Thrust Examination

m.

Dev. Apraxia of Speech Evaluation

n.

Dysarthria Examination

o.

Phonological Process Analysis

p.

Distinctive Feature Analysis

q.

Computer Assisted Analysis

Child Language Part A: Demonstrate the ability to elicit, transcribe and analyze one 50 word utterance

language sample according to at least 3 of the following procedures

Evaluation Name Date Supervisor Signature Rating

a.*

MLR/MLU

b.*

Simple Sentence Analysis

c.*

Type-Token Ratio

d.

Pragmatic Analysis

e.

Semantic Analysis

f.

Computer Assisted Assessment

Child Language Part B: Demonstrate the ability to administer, score and interpret at least 6 of the

following instruments

76

Evaluation Name Date Supervisor Signature Rating

a.*

Preschool Language Scale (PLS- )

b.*

Comprehensive Evaluation of

Language Function (CELF- )

c.*

Peabody Picture

Vocabulary Test (PPVT- )

d.

Comp Comprehensive Assessment of Spoken

Language (CASL-)

e.

Presc Preschool Language Assessment

Instrument (PLAI-)

f.

Test of Language Development

(TOLD- )

g.

The Assessment of Child

Language (TACL- )

h.

Oral a Oral and Written Language Scales (OWLS-)

i.

RecepReceptive One Word Picture Vocabulary

Test (ROWPVT-)

j.

Expre Expressive One Word Picture Vocabulary

Test (EOWPVT-)

Adult Language (1 required in the Adult Area)

a.

Bosto Boston Diagnostic Aphasia Evaluation

(BDAE-)

b. Ross IRoss Information Processing Assessment

(RIPA-)

c. Com Communication Abilities of Daily Living

(CADL-)

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d.

Other-

Reading: Demonstrate the ability to perform and interpret results from the following procedures Evaluation Name Date Supervisor Signature Rating a. Gray Oral Reading Test (GORT- )

b. Woodcock Johnson Diagnostic Reading Battery

c. Other-

Cognition: Demonstrate the ability to perform and interpret results from the following procedures Evaluation Name Date Supervisor Signature Rating a. Burns Brief Inventory of

Communication and Cognition

b. Test of Non-Verbal Intelligence (TONI- )

c. Mini Mental Status Exam

d. Other-

Fluency: Demonstrate the ability to elicit, transcribe, analyze, and interpret at least 2 of the following Evaluation Name Date Supervisor Signature Rating a. Stuttering Severity Instrument (SSI- )

b. Total Dysfluency Index

c. Specific Disfluency Index

d. Proportion of Specific Dysfluency

e. Disfluencies Per Minute

f. Frequency of Accessory Features

g. Other-

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Voice/Resonance: Demonstrate the ability to perform and interpret from the following procedures Evaluation Name Date Supervisor Signature Rating a. Quality

b. Pitch

c. Intensity

d. Resonance

e. Other-

Dysphagia: Demonstrate ability to sample and describe normal/abnormal dimensions of at least 2 of the following vocal characteristics Evaluation Name Date Supervisor Signature Rating a. Complete Swallowing Screening Form

b. Bedside Evaluation

c. Modified Barium Swallow

d. Dietary Nutritional Assessment

e. Fiberoptic Endoscopic Evaluation of Swallowing

f. Other-

Audiometrics: Demonstrate ability to perform, interpret, troubleshoot, and make appropriate referrals concerning the following Evaluation Name Date Supervisor Signature Rating a.* Patient Case History with regards to

Risk Factors/Red Flags

b.* Screening Procedures: Tympanometry, Reflexes, Otoscopy and Pure Tones

c. Optoacoustic Evaluation (OAF)

d. Other-

CLINICAL SKILLS AND KNOWLEDGE OF THE PROFESSION

Case History: Demonstrate the ability to perform and interpret results from the following procedures

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Skill Date Supervisor Signature Rating a.* Parent/Child

b.* Adult

Code of Ethics: Demonstrate knowledge of profession Skill Date Supervisor Signature Rating a.* American Speech Language Hearing

Association (ASHA)

b.* Oklahoma Board of Examiners in Speech Language Pathology and Audiology (OBESPA)

Professional Documentation: Demonstrate the ability to effectively complete clinical paperwork Skill Date Supervisor Signature Rating a.* Writes appropriate Behavioral

Objectives using Evidence-Based Practice

b.* Writes Sessions Notes Using The S.O.A.P Model

c.* Writes Appropriate and informational Diagnostic Reports

d.* Follows HIPPA Rules of Patient Confidentiality

e.* Charts Progress and Keeps Records

MANAGEMENT

Articulation Management: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 2 of the following procedures Technique Date Supervisor Signature Rating a.* Traditional

b.* Phonological Processing

c. Multiple Phoneme

d. Distinctive Feature

e. Minimal Contrast

f. Tongue Thrust

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g. Acquired Apraxia

h. Developmental Apraxia

i. Dysarthria

j. Group Therapy

k. Other-

Language Management: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 4 (1 must be in the adult area) of the following management procedures Technique Date Supervisor Signature Rating a. Syntax:

Traditional-i.e. Behavior Modification, systematic auditory visual cueing

Syntax: Indirect-i.e. Play Therapy, Modeling/Expansion

b. Semantics: Traditional-i.e. Behavior Modification, systematic auditory visual cueing

Semantics: Indirect-i.e. Play Therapy, Modeling/Expansion

c. Pragmatics: Traditional-i.e. Behavior Modification, systematic auditory visual cueing

Pragmatics: Indirect-i.e. Play Therapy, Modeling/Expansion

d. Computer Assisted

e. Augmented or Alternative Communication (high or low)

f. Other-

Language Management-Adult a. Aphasia Therapy

b. Cognitive Therapy

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c. Computer Assisted

d. Augmented or Alternative Communication (high or low)

e. Other-

Reading Comprehension Management: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 2 of the following management procedures Technique Date Supervisor Signature Rating a. Blanks

b. Phonics+5

c. Golden Gate

d. Other-

Fluency Management: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 2 of the following management procedures Evaluation Date Supervisor Signature Rating a. Indirect

b. Fluency-Enhancing

c. Traditional Stuttering Modification

d. Supplemental Rate/Rhythm/Intensity

e. Other-

Voice/Resonance Management: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 2 of the following management procedures Evaluation Date Supervisor Signature Rating a. Vocal Hyperfunction

b. Vocal Hypofunction

c. Pitch Modification

d. Intensity Modification

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e. Resonance

f. Laryngectomy (Alaryngeal Speech)

g. Computer Assisted

h. Other-

Dysphagia Management/Feeding/Swallowing: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 2 of the following management procedures Technique Date Supervisor Signature Rating a. Supraglottic Swallow

b. Superglottic Swallow

c. Effortful Swallow

d. Mendelsohn Maneuver

e. Masako Maneuver

f. Postural Changes

g. Improving Oral Sensory Awareness

h. Modification of Volume and Speed of Food Presentation

i. Intraoral Prosthetics

Oral Motor: Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 2 of the following management procedures Technique Date Supervisor Signature Rating a. Oral Motor Control Exercises

b. Oral and Pharyngeal Rom Exercises

c. Sensory-Motor Integration Procedures

PERSONAL INTERACTION Conferences a.* Prepared for Conferences

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b.* Accepts Suggestions and Openly

Discusses Them in a Non-Defensive Manner

Professional Attitude a.* Interactions with Clients and/or

Caretakers

b.* Interactions with Supervisors

c.* Interactions with Peers

Professional Behavior a.* Appropriate Clinical Attire

b.* Dependable

c.* Flexible

d.* Observe Confidentiality

e.* Communicates Appropriately

ADDITIONAL REQUIREMENTS

Demonstrate the ability to select, organize, and utilize materials which are appropriate for at least 4 of the following populations Population Date Supervisor Signature Rating a.* School Age

b.* Adult

c. Preschool

d. Hearing Impaired

e. Developmentally Delayed

f. Neurologically Impaired

g. Multicultural

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PUBLIC SCHOOL INTERNSHIP

Individualized Education: Demonstrate the ability to select organize, and utilize materials which are appropriate for at least 7 of the following steps a.

Record of Access

b. Record of Parent Contact

c. MEEGS

d. Written Notification of Meeting

e. Authorization to Transfer Records or Consent to Release Confidential Information

f. IEP Present Level of Function

g. IEP Annual Goals and Benchmarks

h. IEP Special and Related Services

i. IEP Transition Services

j. IEP Extended School Year

k. IEP District and State Assessments

l. IEP Documentation of Least Restrictive Environment (LRE)

m. Assisted In the IEP Conference, Initial Placement

n. Review IEP

o. Independently Present IEP Information in the IEP Conference

MEDICAL INTERNSHIP *You might want to consider a similar collection of forms from your medical internship as well. Because each medical facility varies greatly in their documentation, this will not be required. However, someday you may find the forms, checklists, or guidelines to be of benefit. ADDITIONAL PROFESSIONAL PRACTICES

85

Technique Date Supervisor Signature Rating

Northeastern State University

Speech-Language Pathology Clinical Practicum Record

86

Age Group Activity Student: ______________________________________

Code: A=Adult E= Evaluation Semester/YR: ________________________________ C=Child S= Screening Coop SLP: ____________________________________ M= Management Site:___________________________________________

Date Client

(IND/GRIP) Code Lang. Artic. Voice Flu. Dys. Aud. Staff SLP

Initials Supervisor

Cumulative Totals This Page (Page of )

Child Evaluation/Screening

Child Management

Adult Evaluation/Screening

Adult Management

Totals:

Lang. Artic. Voice Flu. Dys. Aud. Staff

87

Speech and Hearing Clinic End of Semester Referral Form

Name of Client_________________________________________________________________________ Address______________________________________________________________________________

88

Phone Number_________________________________________________________________________ Dismiss from Therapy____________________________ Continue Therapy________________________ If therapy is continued, check the type of problem(s) and circle the days and times the client is available for therapy for next semester. Type of Problem: _____Articulation _____ Language _____ Stuttering _____ Voice _____ Aphasia _____ Hearing _____ Acquired Apraxia _____ Developmental Apraxia _____ Augmentative _____ Other Clinician_______________________________ Date __________________________

Northeastern State University Speech-Language Hearing Clinic

Speech-Language Evaluation Plan

Identifying Information

Student Clinician

Evaluation Date Evaluation Time

Client Client DOB Client Age

89

Presenting Complaint

Evaluation Plan

Specific History Information Needed

( ) Oral Mechanism Examination ( ) Hearing Screening ( ) Middle Ear Screening

Test/Procedure Rationale What specific information will this test/procedure give? Why is that information needed?

Evidence-base

90

Supervisory Response:

( ) approved as submitted ( ) revision requested

Supervisor’s Signature: _________________________________________________________________

Clinical Practice Video Assessment Advanced Clinical Practicum SLP 5152 Name:__________________________________________ Date of Filming:_________________________________

Partner’s Name:_______________________________ Your Client’s Initials:___________________________

Identify what you learned from watching yourself and your partner that will be beneficial to you in future sessions:

Self:

91

Partner:

Identify what could be improved for both yourself and your partner: Self: Partner:

Identify the rationale for both yourself and your partner:

Self:

92

Partner:

Identify reinforcement methods used for both yourself and your partner and judge the effectiveness: Self: Partner:

Clinical Practicum Sites

First Year Graduate Student Fall and Spring Rotations

*You will be placed at one or more of the following sites listed below. Clinics: Northeastern State University Speech-Language Hearing Pathology Clinic-Tahlequah Campus Northeastern State University Speech-Language Hearing Pathology Clinic -Muskogee Campus Northeastern State University Speech-Language Hearing Pathology Clinic-Broken Arrow Campus

93

Schools: Bell Public Schools Belfonte Public Schools Brushy Public Schools Mannford Public Schools Glenpool Public Schools (2) Checotah Public Schools (2)

Internship/Externship Requirements

Checklist for Internships/Externships

CPR Cardiopulmonary Resuscitation

Liability Insurance

Background Check

MMR Measles, Mumps and Rubella

Varicella

94

Hep B Hepatitis B

Drug Screening

Flu Shot

TB Test Tuberculosis (annual, once a year)

*TB Test: if the TB Test comes back positive, you will have to complete a symptoms form

and a chest X-Ray within 90 days.

*Liability Insurance can be obtained through ASHA (MARSH)

Northeastern State University

Daily Lesson Plan

Client _______________ Clinician _____________________________________ Date ____________

Supervisor Initial review ___________ Supervisor Final review _______________________________

Long Term Goals (list 2 or more)

1. ______________________________________________________________________________

______________________________________________________________________________

2. ______________________________________________________________________________

______________________________________________________________________________

3. ______________________________________________________________________________

______________________________________________________________________________

Procedures/Materials

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

95

Rationale/Evidence Based

_____________________________________________________________________________________

_____________________________________________________________________________________

Subjective

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Objective (Short-term Goals)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Assessment

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Plan

_____________________________________________________________________________________

_____________________________________________________________________________________

Supervisor Notes:

Letterhead will go here

Northeastern State University

Speech-Language-Hearing Clinic

Semester Treatment Plan

Name: Name

Date of Birth: March 11, 1999

Age:

Phone: (918)123-4578

Address: 123 Cats Lane Grove, OK 74352

Spouse: Joe

Caregiver:

Referral Source:

96

Graduate Clinician: First Last, B.S.

Supervisor: First Last, M.A., CCC-SLP

Admitting Diagnosis: Mixed Non-Fluent Aphasia

Current Diagnosis: Mixed Non-Fluent Aphasia

Long-Term Goal:

The client will use functional communication skills for social interactions (e.g. greetings, social

encounters, and short questions/simple sentences) with both familiar and unfamiliar individuals

with 90% success.

Short-Term Goal #1:

The client will verbally identify family and friends with 90% accuracy.

Short-Term Goal #2:

The client will verbally identify days of the week and months from a calendar with 70%

accuracy.

Short-Term Goal #3:

The client will verbally express synonyms with 90% accuracy.

Short-Term Goal #4:

The client will verbally identify everyday conversational phrases with 80% accuracy.

Short-Term Goal #5:

The client will verbally identify hours and minutes from an analog clock with 70%

accuracy.

Short-Term Goal #6:

The client will formulate 3-word utterances to communicate daily needs in response to

pictures with 75% accuracy with minimal clinician cueing.

Date:

January 01, 2017

Signatures:

_________________________ ___________________________

First Last, B.S. First Last, (M.A.orM.Ed), CCC-SLP

Graduate Clinician Supervisor

97

Letterhead will go here

Northeastern State University

Speech-Language-Hearing Clinic

CASE NOTE

Name: Date:

Address: Birthdate:

Phone: Age:

Supervisor: Examiner:

98

Any information that needs to be stated about the client regarding but not limited to

discharge or hold on services.

Signatures:

_________________________ ___________________________

Your first and last name, B.S. SupervisorName,(M.A.or M.Ed.),CCC-SLP

Graduate Clinician Supervisor

Letterhead will go here

Northeastern State University

Speech-Language-Hearing Clinic

Diagnostic Report

Name: Make sure this side lines up so it is easier to read

Date of Birth: January 1, 2001

Age:

Address:

Phone:

Parents: Sometimes, you will list the spouse

Referral Source:

Graduate Clinician:

Supervisor:

Diagnosis:

Introduction:

99

Client First and Last Name, a 2-year-old female, received a speech and language evaluation on

October 31, 2016, at the Northeastern State University Speech-Language-Hearing Clinic in

Broken Arrow. Client has been receiving speech services at Northeastern State University

Speech-Language and Hearing Clinic since Summer of 2016. Client was evaluated on June 12,

2016. Client is currently scheduled for 30-minute treatment sessions, twice a week. Client has

received previous therapy services at the Scholl Center for Communication Disorders in Tulsa.

She was accompanied by her mother who reported, Client did not start talking until she was 3

years of age. She had a normal birth history, no known ear infections, and no family history of

hearing loss.

Tests Administered:

list and explain test and test results here, example to follow:

The Emerging Literacy & Language Assessment Record Form (ELLA) is a clinical tool used to

assess literacy and language of children. The ELLA assessed three areas, including: Phonological

Awareness and Flexibility, Sign and Symbol Identification and Interpretation, and Memory,

Retrieval, and Automaticity. The Emerging Literacy and Language Assessment (ELLA) is for

ages 4.6 to 9.11. The normal range for this test is between 85 and 115. The mean is 100 with

increments of 15 Standard Deviations. The results are summarized below:

Section

Standard Score

Percentile Rank

Age Equivalent

Phonological

Awareness and

Flexibility

#

#

#

Sign and Symbol

Identification and

Interpretation

#

#

#

Memory, Retrieval,

and Automaticity

#

#

#

Phonological Awareness and Flexibility:

Letter-Sound Identification

Rhyme Awareness

Initial Sound Identification

100

Blending Words

Blending Syllables

Blending Sounds

Segmenting Words

Segmenting Syllables

Segmenting Sounds

Sound Deletion- Initial Position

Sound Deletion- Final Position

Sound Substitution- Initial Position

Sound Substitution- Final Position

Sign and Symbol Identification and Interpretation:

Environmental Symbols

Letter- Symbol Identification

Word Reference Association

Reading Comprehension

Memory, Retrieval, and Automaticity:

Rapid Naming

Word Associations

Story Retell

Client received the following standard scores, which places her below the normal range for

Phonological Awareness and Flexibility. Scores from Sign and Symbol Identification and

Interpretation, and Memory, Retrieval, and Automaticity revealed Client to be above average.

Behavioral Observations:

Client is an intelligent girl with a sweet personality. Client participated in all evaluation activities

required of her. She had an immediate response time and maintained attention throughout

testing.

Conclusion/Recommendations:

Results from the ELLA indicate Client should receive speech and language therapy once a week

for 30 minutes. Therapy should focus on age appropriate language goals and correcting

articulation errors. The main goal for services will be to increase overall intelligibility and

promote language and literacy skills.

Date:

November 12, 2016

101

______________________________ ______________________________

Your First and last name, B.S. Supervisor name,(M.A.orM.Ed),CCC-SLP

Graduate Clinician Supervisor

Letterhead will go here

Northeastern State University

Speech-Language-Hearing Clinic

Progress Report

Name: First Last

Date of Birth: April, 7, 1992

Age: 7:8

Address: 123456 E. 12th St. Tulsa, OK 74134

Phone: 918-123-4567

Parents:

Referral Source: Tulsa Scottish Rite

Graduate Clinician: Clinician Name, B.S.

Supervisor: Supervisor Name, M.A., CCC-SLP

Diagnosis: Speech Delay

Introduction:

Name is a 7-year old female who has been receiving speech services at Northeastern State

University Speech-Language and Hearing Clinic since Summer of 2011. Name was evaluated on

June 13, 2011. Name is currently scheduled for 30-minute treatment sessions twice a week.

102

Name has received previous therapy services at the Scholl Center for Communication Disorders

in Tulsa. She was accompanied by her mother who reported, Name did not start talking until she

was 5 years of age. She had a normal birth history, no known ear infections, and no family

history of hearing loss, per mother report.

Reporting Period:

September 1, 2016 - December 1, 2016

Goals and Objectives:

Name has received therapy at Northeastern State University Speech-Language and Hearing

Clinic for 21 sessions during the 2016 Fall semester. Name attended therapy sessions, scheduled

twice a week for 30 minutes. Name’s attendance record was excellent only missing 2 therapy

sessions.

Long-Term Goal #1:

The client will produce the /r/ speech sound with 90% mastery.

Ongoing Goal

Short-Term Goal #1: The client will verbally produce /r/ in initial position of words with 90% accuracy.

Pretest: 70% Posttest: 80%

Ongoing Goal

Short-Term Goal #2:

The client will verbally produce /r/ in medial position of words with 90% accuracy.

Pretest: 50% Posttest: 70%

Ongoing Goal

Short-Term Goal #3:

The client will verbally produce /r/ in final position of words with 90% accuracy.

Pretest: 65% Posttest: 75%

Ongoing Goal

Long-Term Goal #2:

The client will produce words with S-blends when prompted by clinician with 90% mastery.

Goal Achieved

Long-Term Goal #3:

The client will increase auditory comprehension to 90% mastery.

Goal Achieved

Short-Term Goal #4:

The client will follow two-step commands when prompted by clinician with 90%

103

accuracy.

Pretest: 75% Posttest: 90%

Goal Achieved

Short-Term Goal #5:

The client will improve auditory comprehension of sentence recall with 90% accuracy

over two consecutive sessions.

Pretest: 75% Posttest: 90%

Goal Achieved

Testing Completed:

Hearing Screening

Oral Mechanism Evaluation

Emerging Literacy & Language Assessment (ELLA)

Hearing Screening

Pure tone hearing screenings were completed on 11/01/2016 and 09/20/2016 at 25 decibels.

Name was instructed to raise her hand when pure tone sound was heard. The client was within

normal limits on frequencies tested. Results from those screenings revealed no signs of a hearing

impairment.

Date: 11/01/2016 500 Hertz 1000 Hertz 2000 Hertz 4000 Hertz

Left Ear Yes Yes Yes Yes

Right Ear Yes Yes Yes Yes

Date: 09/20/2016 500 Hertz 1000 Hertz 2000 Hertz 4000 Hertz

Left Ear Yes Yes Yes Yes

Right Ear Yes Yes Yes Yes

Oral Mechanism Examination

This examination was conducted on September 13, 2016 to assess the structure and function of

the oral speech mechanism. Structures and functions appeared normal.

Emerging Literacy & Language Assessment (ELLA)

The Emerging Literacy & Language Assessment Record Form (ELLA) is a clinical tool used to

assess literacy and language of children. The ELLA assessed three areas, including: Phonological

Awareness and Flexibility, Sign and Symbol Identification and Interpretation, and Memory,

Retrieval, and Automaticity. The Emerging Literacy and Language Assessment (ELLA) is for

ages 4.6 to 9.11. The normal range for this test is between 85 and 115. The mean is 100 with

increments of 15 Standard Deviations. The results are summarized below:

Section

Standard Score

Percentile Rank

Age Equivalent

104

Phonological

Awareness and

Flexibility

77

9

5.10

Sign and Symbol

Identification and

Interpretation

120

73

>9.11

Memory, Retrieval,

and Automaticity

142

94

>9.11

Name received the following standard scores, which places her below the normal range for

Phonological Awareness and Flexibility. Scores from Sign and Symbol Identification and

Interpretation, and Memory, Retrieval, and Automaticity revealed Name to be above average.

Summary:

Name made progress on all of her goals this semester. She had a substantial increase in speech

intelligibility in structured and conversational speech. She demonstrated initiation and

maintenance of using strategies (e.g. placing tongue in correct placement and repeating incorrect

speech production) to express correct articulation. She is displaying a delay in her language

skills as well as a delay in articulation of the /r/ phoneme. The connection between therapy and

home will be a contributing factor to Name’s future success.

Recommendations:

Based on Name’s progress this semester, the following recommendations are made:

1. Reduce speech therapy for 30-minute sessions, once a week.

2. Continued practice of strategies outside of therapy is critical to Name’s ongoing progress in

developing expressive language skills.

3. Develop stronger skills related to rhyming.

4. Implement goals toward receptive and expressive language.

5. Continue working on production of the /r/ speech phoneme with 90% mastery.

Date:

December 1, 2016

Signatures:

______________________________ ______________________________

105

Your First and last name, B.S. Supervisor name,(M.A.orM.Ed),CCC-SLP

Graduate Clinician Supervisor

Northeastern State University

Speech-Language Pathology Clinic Semester Progress Report: Fall 2019

Name: B H Date: 4-1-2019

Address: 800 N Grand D.O.B.: 9-23-1998

Tahlequah, OK 74464 Age: 15 Years 7 months

Clinician: Suzy Speech Path, B.S. Supervisor: Supervisor Q, M.S., CCC-SLP

Admitting Diagnosis:

Severe Language Disorder.

Current Diagnosis:

Severe Language Disorder.

Reporting Period:

The client attended 11 out of the 13 regularly scheduled sessions which met one day a week for 60

minutes.

Status at the beginning of the reporting period:

B was brought to the Northeastern State University Speech-Language-Hearing Clinic by client’s

mother. At the beginning of the semester B had severe receptive and expressive language difficulties.

B seemed tired at the beginning of the sessions but he cooperated with the clinician at all times.

Testing:

The Comprehensive Assessment of Spoken Language (CASL) was administered to B on January 22,

2014. The following scores were obtained:

Standard Score Percentile

Core Composite 62 1%

106

Core Subtests Standard Scores

Antonyms 56

Synonyms 87

Syntax Construction 60

Idiomatic Language 73

Grammatical Morphemes 78

Nonliteral Language 77

Meaning for Context 40

Pragmatical Judgment 40

Sentence Completion 78

Inference 75

EBP:

Taylor-Goh, S. ed(2005). RCSLT Clinical guidelines. Blcster, Speachmark Publishing Ltd.

Semester Goals: Pre-Test Post-Test

1. B will increase receptive and expressive language skills by completing and giving examples of novel idioms to 80% accuracy.

60% 75%

2. B will name the antonym of word given by clinician with 90% accuracy.

55% 80%

3. B will use context to determine meaning of novel words to 80% accuracy.

33% 75%

Summary Comments and Conclusions:

B made significant progress in therapy. He was very cooperative and worked hard during therapy. A

game was used to keep client motivated in between activities.

Recommendations:

It is recommended that B continue to receive language therapy services for one hour per week to

improve his language skills.

_______________________________ _______________________________

Suzy Speech Path, B.S. Supervisor Q, M.S.., CCC-SLP

Graduate Clinician Clinical Supervisor

107

SPEECH-LANGUAGE-HEARING CLINIC Northeastern State University

ATTENDANCE RECORD Client______________________________________ Clinician_____________________________________ Semester__________________________________

Week Monday Tuesday Wednesday Thursday Date

1

2

3

4

5

6

7

8

108

9

10

11

12

13

14

15

16

Mark the amount of time (1 hour or ½ hour) for days attended. Client________________________________________ Clinician______________________________________

Date Case Notes

109

NAME OF CHILD:_____________________________________ PARENTS:____________________________________ First Middle Last BIRTHDATE:_______________________ ADDRESS:______________________________________________________ month/day/year Street or P.O. BOX City State Zip DISTRICT/AGENCY:_______________________________PHONE:_________________________________________ Home/Work

RECORD OF PARENT CONTACT DATE

Month/Day/Year Purpose of

Contact Method of

Contact Person Making

Contact Results

110

NAME OF CHILD________________________________________ BIRTHDATE______________________________ Month/Day/Year

RECORD OF ACCESS SIGNATURE PURPOSE FOR ACCESSING RECORDS DATE

111

Speech-Language-Hearing Clinic

Northeastern State University

600 N. Grand Ave

Tahlequah, OK 74464

Instructions: Please read this admission form carefully. There are several sections that require your signature. If

you have any questions or concerns about this form, please inform the admitting supervisor(s).

ADMISSION FOR CLINICAL SERVICES FORM ASHA Code of Ethics: Principle of Ethics I, Rules of Ethics C.

Individuals shall not discriminate in the delivery of professional services or the conduct of research and scholarly activities

on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability.

I request admission to the clinical services offered by Northeastern State University’s Speech and Hearing

Clinic.

PLEASE PROVIDE THE FOLLOWING INFORMATION Please print

Client’s Full Name _____________________________________Birthdate _______________

Parent/Legal Guardian’s Name ___________________________________________________ If applicable.

Street _______________________________________________________________________

City _____________________________ State _____ Zip ________ Phone _______________

Date: _______________________

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RECEIPT OF PRIVACY NOTICE

I acknowledge that I have received the attached Notice of Privacy Practices

Please retain the copy of privacy practices for your records

________________________________________________ ______________ Client’s or Legal Guardian’s Signature Date

Relationship to the client: ___ Self ___ Parent ___ Legal Guardian ___

Other: Please explain ______________________________________________________________

CONSENT FOR SUPERVISED SERVICES AND

AUDIO/VIDEO RECORDING

I understand that the clinical services are provided by student clinicians in the Northeastern State

University’s Speech-Language Pathology Program working under the direct supervision of

professional speech-language pathologists certified by the American Speech-Language-Hearing

Association and licensed by the Oklahoma State Board of Examiners in Speech Language

Pathology; that the sessions may be observed, video/audio recorded by those in the professional

training program; that the reports may be read by authorized persons in the professional program

and that information from the diagnostic and therapy sessions may be used for educational and

research purposes.

________________________________________ __________________

Client or Parent/Legal Guardian’s Signature Date

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CONSENT FOR INITIAL EVALUATION

I, ________________________________________, give my consent for speech/language/hearing

evaluation procedures conducted by student clinicians under supervision of professional Speech-

Language Pathologists and Audiologists in the Northeastern State University Speech-Language-

Hearing Clinic.

Date:____________________ Reason for Evaluation:___________________________________

_______________________________________________________________________________

_______________________________________________________________________________

___________________________________________ ____________________

Client or Parent/Legal Guardian’s Signature Date

CONSENT FOR SPEECH/LANGUAGE THERAPY

I, ______________________________________, have been advised that speech/language therapy

is recommended by the evaluation team. I have been explained the nature of the speech, language,

and/or literacy therapy required. I agree that the proposed treatment plan has been explained to

me and I understand that the length of time and commitment from me is required for therapy to be

effective. I agree to allow students/supervisors to observe me/my child, during treatment. I

understand that I may cancel therapy at any time if I so choose.

_____________________________________________ ____________________

Client’s or Parent/Legal Guardian’s Signature Date

TRANSPORTATION OF CLIENT/CHILD

In the event that I, __________________________________, cannot transport my child from the

Speech-Language Therapy Clinic, I give permission for other individuals to assist in the

transportation. I must inform the child’s student clinician and the secretary/supervisor in advance of

this request and give them the name of the individual who will be transporting the child. I will not

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hold the Speech-Language-Hearing Clinic personnel legally responsible for permitting the child to

accompany the named individual.

_____________________________________________ ____________________

Client’s or Parent/Legal Guardian’s Signature Date

EXCESSIVE ABSENCES

I, _________________________________, understand the Speech-Language Clinic holds the right

to discontinue Speech-Language Services in the event of excessive absences. Excessive absences

constitute, but are not limited to, excessive cancellations or no shows to sessions. The decision to

discharge due to absences will be at the discretion of the clinic director and program chair.

____________________________________________ _________________

Client’s or Parent/Legal Guardian’s Signature Date

Northeastern State University Speech-Language Hearing Pathology Clinic Folder Checklist

DATE:

Record of Access to Educational Records

Record of Parent Contact

Progress Report Tab:

Attendance Record

Semester Progress Report

Reports Tab:

Testing/Speech/Language Evaluation

School IEP Goals

Consent Tab:

Disclosure Statement and Express Assumptions of Risk

Admission for Clinical Services

Audio/Video Recording Consent

Consent for Initial Evaluation

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Consent for SLP Therapy

Transportation of Client

Payment for Services Rendered

Authorization to Release Information (child)

Privacy Policy

Case History Tab:

Case History Form

Key: + Present N/A Not Applicable ___ Missing

I have read, reviewed, understand and agree to abide by the NSU Speech-Language-Hearing Clinic Handbook. _______________________________________ _____________________ NSU SLP Student Date _______________________________________ _____________________ Witness Date

S i g n a t