APPENDIX H
THE OBSERVATION/CONTACT TIME SUBMISSION FORM, THE NON-
CONTACT/MODIFICATION TIME SUBMISSION FORM
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Southern Connecticut State University
Department of Communication Disorders
Observation/Contact Time Submission Form
Speech Language Pathology
(Please type, or print legibly)
Student:_____________________________________________________________________________________________
(First Name) (Last Name) (Date)
Address:____________________________________________________________________________________________
(Number and Street) (Apartment Number)
____________________________________________________________________________________________________
(City) (State) (ZIP Code)
Communication:_____________________________________________________________________________________
(Stationary Phone) (Cell) (Email)
PLEASE CONSULT DIRECTIONS ON THE BACK OF THIS FORM BEFORE COMPLETING
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PRAC NUMB |
GRAD |
UNIV |
SEM |
YEAR |
SRVCE CODE |
AGE CODE |
OBS HRS |
DX HRS |
TX HRS |
SITE CODE |
SUPERVISOR FULL NAME (F, M, L) PRINTED AND SIGNATURE |
ASHA ACCOUNT # AND AREA OF CERTIFICATION |
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AGE CODES: |
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SERVICE CODES: |
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Child (Under 18 years)........................................... Adult..........................................................................
SITE CODES(Please see back): Rehab./Hospital..................................................... University Clinic..................................................... Private Practice....................................................... Community............................................................. School......................................................................
GRAD CODES: Graduate Hours...................................................... Undergraduate Hours............................................ |
C A
1 2 3 4 5
Y N |
Articulation............................................................................. Fluency.................................................................................. Voice and Resonance........................................................... Receptive and Expressive language Disorders.................... Hearing.................................................................................. Swallowing Disorders........................................................... Other Communication Modalities........................................ Cognitive Aspects of Communication................................. Social Aspects of Communication....................................... Counseling............................................................................. Emerging Areas of Practice................................................ |
01 02 03 04 05 06 07 08 09 10 11
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Observation/Contact Time Submission Form
Directions
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PRAC NUMB
GRAD
UNIV
SEM
YEAR
SERVICE CODE
AGE CODE
OBS HRS
DX HRS
TX HRS
SITE CODE
SUPERVISOR FULL NAME AND SIGNATURE
ASHA ACCOUNT # AND AREA OF CERTIFICATION |
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Course number of the practicum to which contact hours on this line refer. If hours are from an undergraduate program or are observation hours, you may leave this cell blank.
Indicate ‘Y’ if hours were obtained in a graduate program, ‘N’ if hours were obtained in an undergraduate program according to GRAD CODES.
University at which you were matriculated when hours on this line were obtained.
Indicate the semester (Fall, Spring, Summer) in which hours on this line were obtained.
Indicate calendar year in which hours on this line were obtained.
Indicate according to the SERVICE CODES, the communication disorder or difference for which you accumulated clinical contact hours recorded on this line. You may indicate only one code per cell, per line. If the client presents with more than one disorder for which you wish to record hours, you must use one line for each disorder.
Indicate according to the AGE CODES, the age of your client for whom the hours on this line refer. You must use a separate line for each client or group of clients of different ages.
Indicate the number of observation hours accumulated for client(s) presented on this line. If you are submitting hours from a program external to SCSU a signature in the SUPERVISOR SIGNATURE column is not needed. You must, however, provide signed validation of the observation hours recorded. Copies of your validation documents must be attached to this form.
Indicate the number of diagnostic hours accumulated for client(s) presented on this line.
Indicate the number of treatment hours accumulated for client(s) Presented on this line.
Indicate according to the SITE CODES, the type of practicum site at which hours on this line were obtained. Important: record the actual site name and address in your records for use as part of your KASA information.
Please print clearly the full name (first, middle/maiden, last) of the supervisor of the hours on this line. Ask your supervisor to sign your submission form on this line. You must use a separate line for each supervisor recorded.
Indicate the ASHA account number of the supervisor of the client(s) recorded on this line. Be sure to include in this same space, the supervisor’s area of ASHA certification, SLP, A, SLP/A.
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Please be advised: your submission form must be produced in ink. Photocopies are not accepted. Further, your form will not be accepted if it contains erasures, mark-outs, strikeovers, or any modification of a recorded number.
Southern Connecticut State University
Department of Communication Disorders
Non-Contact/Modification Time Submission Form
Speech Language Pathology
(Please type, or print legibly)
Student:______________________________________________________________________________________
(First Name) (Last Name) (Date)
Address:______________________________________________________________________________________
(Number and Street) (Apartment Number)
_____________________________________________________________________________________________
(City) (State) (ZIP Code)
Communication:_______________________________________________________________________________
(Stationary Phone) (Cell) (Email)
PLEASE CONSULT DIRECTIONS ON THE BACK OF THIS FORM BEFORE COMPLETING
|
SERVICE CODE |
SEM |
YEAR |
AGE CODE |
DX HRS |