Speech & Language Pathologist: Supervised Professional Experience Verification

Public Health: Supervised Professional Experience Report

DPH Data Management and Governance (PLIS)
Speech Pathology
Last Name:*
First Name:*
Middle Name:
Maiden Name:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone No:*
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: *
SPE Setting
Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date:

MonthDayYear
Ending Date:

MonthDayYear
Calendar YearAcademic Year
If Academic Year, Inclusive Dates Of Employment:
From:
To:
From:
To:
How many hours did the candidate work per week?
Speech Pathology:
Hours
Audiology:
Hours
YesNo
If no, please explain (use additional sheets as necessary):
SPE Supervisor:
Name:
Professional Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CT License No:
Date Issued:

MonthDayYear
Telephone No:
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. EVAL.	6 MONTH. EVAL.	9 MONTH EVAL.
ASSESSMENT, DIAGNOSIS/OR EVALUATION
HABILITATION, REHABILITATION
DEFINING GOALS AND OBJECTIVES
CLIENT/PARENT COUNSELING
PROFESSIONAL RELATIONSHIPS
RECORD KEEPING

Briefly describe the applicants strengths and weaknesses:
YesNo
Please Explain:
YesNo
Please Explain:
YesNo
Please Explain:
I have discussed this report with my SPE supervisor:
Applicant Signature:
Date:
I have discussed this report with the above named applicant:
Supervisor Signature:
Date:
NOTE: THE ORIGINAL REPORT MUST BE SUBMITTED BY THE SUPERVISOR DIRECTLY TO THE DEPARTMENT OF PUBLIC HEALTH, SPEECH PATHOLOGY LICENSURE, 410 CAPITOL AVE., MS# 12APP, P.O. BOX 340308, HARTFORD, CT 06134.

If you have questions, do not hesitate to contact this office at (860)509-8378.
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Public Health: Supervised Professional Experience Report

Speech Pathology

SPE Setting

SPE Supervisor: