Speech & Language Pathologist: Supervised Professional Experience Verification -- Non-CT

Public Health: Speech and language pathology / audiology licensure

DPH Data Management and Governance (PLIS)
verification of out-of state postgraduate supervised professional experience (SPE)
Area Of Experience: Speech And Language Pathology
Name of applicant:
First Name:*
Last Name:*
Middle Name:
Maiden Name:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Academic status
Degree:*
Date conferred:*
Name of university: *
Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SPE Setting
Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date of SPE:

MonthDayYear
Ending Date:

MonthDayYear
Calendar yearAcademic year
If calendar year, inclusive dates of employment:
From:
To:
From:
To:
Number of hours per week:
SPE Supervisor:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
License/certificate # :
State:
Date Issued:

MonthDayYear
Place of employment:
Address:

Street 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	EVALUATION
ASSESSMENT, DIAGNOSIS/OR EVALUATION
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:
YesNo
Please Explain:
YesNo
Please Explain:
YesNo
Please Explain:
Date

MonthDayYear
Supervisor's Signature:
NOTE: This verification should be submitted by the supervisor directly to the Department of Public Health, 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:

Public Health: Speech and language pathology / audiology licensure

verification of out-of state postgraduate supervised professional experience (SPE)

Area Of Experience: Speech And Language Pathology

Name of applicant:

Academic status

SPE Setting

SPE Supervisor: