Audiologist -- Supervised Professional Experience -- CT

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
SUPERVISED PROFESSIONAL EXPERIENCE REPORT
AUDIOLOGY
LAST NAME
Last Name
FIRST NAME
First Name
MIDDLE NAME
Middle Name
MAIDEN NAME
Maiden Name
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TELEPHONE NUMBER
WHERE YOU CAN BE REACHED MON. - FRI., 8:30 a.m. - 4:30 p.m. Format: (000) 000-0000.
EMPLOYMENT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CAREER OBJECTIVES
Career Objectives
SPE SETTING: NAME

SPE SETTING NAME

Address

CityState / Province

Postal / Zip Code
BEGINNING DATE

MonthDayYear
ENDING DATE

MonthDayYear
DID APPLICANT WORK
IF ACADEMIC YEAR, INCLUSIVE DATES OF EMPLOYMENT:

MonthDayYear
To

MonthDayYear
From

MonthDayYear
To

MonthDayYear
HOW MANY HOURS DID THE CANDIDATE WORK PER WEEK? SPEECH PATHOLOGY
Number of Hours
HOW MANY HOURS DID THE CANDIDATE WORK PER WEEK? AUDIOLOGY
Number of Hours
WAS THE SPE PLAN IMPLEMENTED EXACTLY AS SUBMITTED?
IF NO, PLEASE EXPLAIN (USE ADDITIONAL SHEETS AS NECESSARY):
Enter Explanation
SPE SUPERVISOR:
NAME

First NameLast Name
PROFESSIONAL ADDRESS

Professional Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CT LICENSE NUMBER
CT License Number
DATE ISSUED

MonthDayYear
TELEPHONE NUMBER
WHERE YOU CAN BE REACHED Mon. - Fri. 8:30 a.m. - 4:30 p.m.Format: (000) 000-0000.
SUPERVISOR: AT THE CONCLUSION OF THREE, SIX AND NINE MONTHS OF THE SPE, PLEASE EVALUATE THE APPLICANT’S COMPETENCY IN EACH OF THE PROFESSIONAL SKILL AREAS SPECIFIED; USE THE FOLLOWING RATING SCALE AND ENTER THE APPROPRIATE RATINGS IN THE EVALUATION RECORD BELOW.

1. ABLE TO FUNCTION COMPETENTLY WITHOUT SUPERVISION.
2. ABLE TO FUNCTION COMPETENTLY ONLY WITH SUPERVISION.
3. UNABLE TO FUNCTION COMPETENTLY, EVEN WITH SUPERVISION.

SKILL AREA:

Rows	3 MONTH EVALUATION. ENTER 1, 2 or 3.	6 MONTH EVALUATION. ENTER 1, 2 or 3.	9 MONTH EVALUATION. ENTER 1, 2 or 3.
ASSESSMENT, DIAGNOSIS / OR EVALUATION
HABILITATION, REHABILITATION
DEFINING GOALS AND OBJECTIVES
CLIENT/PARENT COUNSELING
PROFESSIONAL RELATIONSHIPS
RECORD KEEPING

BRIEFLY DESCRIBE THE APPLICANTS STRENGTHS AND WEAKNESSES
Enter Explanation
HAS THE APPLICANT DEMONSTRATED DURING THE PROFESSIONAL EXPERIENCE PERIOD THAT HE/SHE IS FULLY COMPETENT TO FUNCTION INDEPENDENTLY AND WITHOUT SUPERVISION?
IF NO, PLEASE EXPLAIN:
Enter Explanation
HAS THE APPLICANT DEMONSTRATED CONFORMANCE WITH ACCEPTED STANDARDS OF PROFESSIONAL PRACTICE DURING HIS/HER SUPERVISED PROFESSIONAL EXPERIENCE?
IF NO, PLEASE EXPLAIN:
Enter Explanation
DO YOU RECOMMEND, BASED ON THE APPLICANT’S DEMONSTRATED LEVEL OF COMPETENCY DURING THE SUPERVISED PROFESSIONAL EXPERIENCE PERIOD, THAT HE/SHE BE ISSUED A LICENSE TO FUNCTION INDEPENDENTLY?
IF NO, PLEASE EXPLAIN:
Enter Explanation
I HAVE DISCUSSED THIS REPORT WITH MY SPE SUPERVISOR.
APPLICANT'S SIGNATURE
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
DATE

MonthDayYear
I HAVE DISCUSSED THIS REPORT WITH THE ABOVE NAMED APPLICANT.
SUPERVISOR'S SIGNATURE
Enter Full Legal Name
By checking this box I affirm or attest that this is my legal signature.
DATE

MonthDayYear
NOTE: THE ORIGINAL REPORT MUST BE SUBMITTED BY THE SUPERVISOR DIRECTLY TO:

THE DEPARTMENT OF PUBLIC HEALTH
AUDIOLOGIST LICENSURE
410 CAPITOL AVE., MS# 12 APP
P.O. BOX 340308
HARTFORD, CT 06134

SHOULD YOU HAVE QUESTIONS, DO NOT HESITATE TO CONTACT THIS OFFICE AT
oplc.dph@ct.gov.
Should be Empty:

STATE OF CONNECTICUT

SUPERVISED PROFESSIONAL EXPERIENCE REPORT