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

Street Address Line 2

CityState / Province

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

MonthDayYear
Name of University

Name of University

Address

CityState / Province

Postal / Zip Code
SPE Setting: Name

Name

Address

CityState / Province

Postal / Zip Code
Beginning Date Of SPE

MonthDayYear
Ending Date

MonthDayYear
Did Applicant Work
If calendar year, inclusive dates of employment: From

MonthDayYear
To

MonthDayYear
From

MonthDayYear
To

MonthDayYear
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

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
Did The Applicant Demonstrate During The Supervised Professional Experience Period That He/She Is Fully Competent To Function Independently And Without Supervision?
If No, Please Explain:
Enter Explanation
Did The Applicant Demonstrate 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
Date

MonthDayYear
Supervisor's Signature
Enter Full Legal Name
By checking this box 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