Non- CT- Audiologist -- Supervised Professional Experience --Non- CT

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
VERIFICATION OF OUT-OF STATE POSTGRADUATE SUPERVISED PROFESSIONAL EXPERIENCE

SPE
Area of Experience: Audiology
Name of Applicant *

First NameLast Name
Middle or Maiden Name

Middle NameMaiden Name
ADDRESS*

Street Address

City, Stare, Zip

CityState / Province

Postal / Zip Code
Academic Status: Degree*
Degree Title
Date Conferred*

MonthDayYear
Name of University*
Name of University
Address*

Street Address

City, State, Zip

CityState / Province

Postal / Zip Code
SPE Setting: Name*

NAME

Street Address

CityState / Province

Postal / Zip Code
Address*

Street Address

City, State, Zip

CityState / Province

Postal / Zip Code
Beginning Date Of SPE*

MonthDayYear
Ending Date*

MonthDayYear
Calendar YearAcademic Year
If calendar year, inclusive dates of employment: From Date* to

Date* ; From Date* to Date* .
Number of Hours Per Week*
Numbers of Hours Per Week
SPE SUPERVISOR
Name

First NameLast Name
ADDRESS

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
License/Certificate Number
License or Certificate Number
State
State
Date Issued

MonthDayYear
Place of Employment
Enter Company or Organization Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Telephone
Please enter a valid phone number. Format: (000) 000-0000.
Email
example@example.com
Supervisor: Please evaluate the level of competency the applicant had achieved at the conclusion of the SPE period in each of the professional skills 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	Enter 1, 2 or 3.
Assessment, Diagnosis/Or Eval.
Habilitation, Rehabilitation
Defining Goals And Objectives
Client/Parent Counseling
Professional Relationships
Record Keeping

Briefly describe the applicant's strengths and weaknesses at the conclusion of the SPE period:
Enter Description
YesNo
If No, Please Explain:
Enter Explanation
YesNo
If No, Please Explain:
Enter Explanation
YesNo
If No, Please explain:
Enter Explanation
Date

MonthDayYear
Supervisor's Signature
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Note: This verification should be submitted by the supervisor directly to:

Department of Public Health
Audiologist Licensing
410 Capitol Ave., MS#12 APP
P.O. Box 340308
Hartford, CT 06134-0308.

If you have any questions regarding this report, please email the department at
oplc.dph@ct.gov.
Should be Empty:

STATE OF CONNECTICUT

VERIFICATION OF OUT-OF STATE POSTGRADUATE SUPERVISED PROFESSIONAL EXPERIENCE