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

City, State, Zip

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

City, State, Zip Code

CityState / Province

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

Name

Street Address Line 2

CityState / Province

Postal / Zip Code
ADDRESS*

Street Address

City, State, Zip

CityState / Province

Postal / Zip Code
BEGINNING DATE*

MonthDayYear
ENDING DATE*

MonthDayYear
CALENDAR YEARACADEMIC YEAR
IF ACADEMIC YEAR, INCLUSIVE DATES OF EMPLOYMENT: FROM Date* TO: Date* ; From: Date* TO: Date* .
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
YesNo
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
YesNo
IF NO, PLEASE EXPLAIN:
Enter Explanation
YesNo
IF NO, PLEASE EXPLAIN:
Enter Explanation
YesNo
IF NO, PLEASE EXPLAIN:
Enter Explanation
I HAVE DISCUSSED THIS REPORT WITH MY SPE SUPERVISOR.
APPLICANT'S SIGNATURE*
Enter Full Legal Name
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
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