MARYWOOD...CSD 521 Supervised clinical practice in the principles and procedures necessary for assessment of speech and language disorders with various populations at the Marywood

MARYWOOD

UNIVERSITY

DEPARTMENT OF COMMUNICATION

SCIENCES AND DISORDERS

SPEECH/LANGUAGE and

AUDIOLOGY CLINICS

Clinic Handbook: Policies and Procedures

The Clinic Handbook was developed for Communication Sciences and Disorders

undergraduate and graduate student clinicians, faculty, and clinical staff. The

purpose of this handbook is to provide information regarding clinical policies and

procedures at the Marywood University Speech/Language and Audiology Clinics.

Students, faculty, and clinical staff are responsible for following the policies and

procedures included in this handbook.

Revised 4/2018

TABLE OF CONTENTS

I. Clinical Practicum Page

Philosophy 3

Clinical Eligibility Requirements 3-4

Eligibility Requirements and Essential Functions for Students 5-6

Practicum Sequence 7

Clinical Education Goals and Objectives 8

Clinical Methods and Processes Coursework 9

Directed Clinical Observations 9

Immunizations and Clearances 9

Immunization/Drug Testing Policy 10

Immunization/Drug Testing Waiver 11

Therapy Observation Forms

12-16

Observation Hours Log Sheet and Summary Sheet

17-18

II. Clinical Education

Speech-Language Therapy Procedures and Clinical Documentation 19-20

Audiology/Aural Rehabilitation Practicum Procedures

20

III. Clinical Practicum Forms

Client File Sequence 21

Communication Log Sheet 22

Attendance Sheet 23

Clinical Services Referral 24-25

Clinical Services Referral Audiology 26

Case History Forms 26-48

Authorization for Release of Information 49

Authorization for Obtaining Information 50

Authorization for Exchange and Use of Clinical Information 51

Clinic Attendance Policy 52

HIPAA Information 53-56

Client Assignment Form 57

Audiology Assignment Form 58

Clinic Information Sheet 59

Initial File Review 60

Weekly Treatment Plan 61-62

Play Group Lesson Plan 63

Pragmatic Group Lesson Plan 64

Data Collection Forms 65-66

Daily Outcome Data Log 67-68

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Session Evaluation Form 69-70

SOAP Notes 71-73

Therapy Progress Report 74-76

Student Performance Evaluations 77

Clinic Observation Forms 78-81

Student Evaluation Forms 82-93

Student Evaluation of Clinical Supervision 94-98

Documentation of Clinical Clock Hours 99-108

Family Satisfaction Survey 109-111

Audiology Satisfaction Survey 112-113

IV. CSD Administrative Policies and Procedures

Confidentiality 114

Code of Ethics 114

Clinician/Client Relationship 114

Speech-Language-Hearing Screening Policy 114-115

Dialectical Difference Statement 115-117

Dress Code 117

Taping 117

Academic and Clinical Conduct and Dispositions Policies 117-120

Hour Accrual Policy 120

Clinic Materials/Diagnostic Tests: Loan Policy 121

Client Referrals 121

Client and Student Clinician Attendance/Cancellations 121-122

Marywood University Holidays and Inclement Weather 122

Clinic Rooms 123

Clinic Telephone Usage 123

Emergency Protocol 123

Universal Precautions 123

Inservices 123

Research 123

Flash Drives 123-124

Cleaning Procedures 124

Anti-Discrimination policy 124

Client Folder Sign Out Log 125

Clinic Materials Sign Out Log 126

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CLINICAL PRACTICUM

PHILOSOPHY

The faculty and clinical staff in the Department of Communication Sciences and Disorders view clinical practicum as an

integral part of preprofessional education in human communicative sciences and disorders. Students involved in practicum

are provided with an opportunity to work with individuals of all ages having various types of communicative disabilities.

Clinical practicum is intended to maximize learning outcomes and follows the requirements set forth by the American

Speech-Language-Hearing Association (ASHA). These practical experiences are provided under the direct supervision of

PA State licensed and ASHA certified speech-language pathologists and audiologists.

Marywood University’s Speech/Language and Audiology Clinics are located in the William G. McGowan Center for

Graduate and Professional Studies. The Clinics meet the needs of several hundred clients annually, providing an array of

diagnostic and therapeutic services. Children and adults are seen for speech, language, and/or hearing services throughout

the year.

CLINICAL ELIGIBILITY REQUIREMENTS

Effective Summer 2014

Students in the Speech-Language Pathology program at Marywood University participate in a variety of clinical/diagnostic

practicum experiences. Prior to any experiences students would have completed training for HIPAA Privacy Rules and the

use of universal precautions. Clinical practicum credits and hours are acquired through clinical preparation at the

Marywood University Speech/Language and Audiology Clinics, part time off-campus placement sites, and full time off-

campus externship sites approved by the department. A description of each clinical practicum and its clinical pre-requisites

are as follows:

CSD 468A Supervised clinical practice in the treatment of speech and language disorders with various clinical

populations at the Marywood University Speech/Language and Audiology Clinics. Pre-requisites:

Documentation of 25 hours of direct observation of an ASHA certified Speech-Language Pathologist

and/or Audiologist; updated immunizations and clearances on file; successful completion of CSD 361 with

a minimum final grade of B-; minimum overall and CSD QPA of 3.25; and permission of the Department

Chairperson.

CSD 470A/B Supervised clinical practice in the treatment of audiological disorders/impairments with various clinical

populations at the Marywood University Speech/Language and Audiology Clinics. Pre-requisites:

Documentation of 25 hours of direct observation of an ASHA or AAA certified audiologist; updated

immunizations and clearances on file; successful completion of CSD 362 with a minimum final grade of

B-; minimum overall and CSD QPA of 3.25; and permission of the Department Chairperson.

CSD 516A Supervised clinical practice in the treatment of speech and language disorders with various clinical

populations at the Marywood University Speech/Language and Audiology Clinics and off-campus settings.

Pre-requisites: Documentation of 25 hours of direct observation of an ASHA certified Speech-Language

Pathologist and/or Audiologist; updated immunizations and clearances on file.

CSD 516B Supervised clinical practice in the treatment of speech and language disorders with various clinical


Pre-requisites: Successful completion of CSD 516A with a minimum final grade of B-; updated

immunizations and clearances on file.

CSD 516C Supervised clinical practice in the treatment of speech and language disorders with various clinical


Pre-requisites: Successful completion of CSD 516B with a minimum final grade of B-; updated


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CSD 519I Supervised clinical practice in the assessment/treatment of speech and language disorders with various

clinical populations at a full time off-campus placement site throughout the semester. Pre-requisites:

Successful completion of CSD 521 with a minimum final grade of B-; CSD 516C with a minimum final

grade of B- or a satisfactory (S) rating if EDUC 597 was taken; permission of the Program Director; 25

hours of supervised practicum by a Marywood University Clinical Supervisor; updated immunizations and

clearances on file; CPR certification on file; and completion of Formative Assessment Manuals per

established requirements.

CSD 520E Supervised clinical practice in the assessment/treatment of speech and language disorders with various

clinical populations at a full time off-campus externship site. Pre-requisites: Successful completion of

CSD 521 with a minimum final grade of B-; CSD 519I with a minimum final grade of B-; permission of

the Program Director; 25 hours of supervised practicum by a Marywood University Clinical Supervisor;

updated immunizations and clearances on file; CPR certification on file; and completion of Formative

Assessment Manuals per established requirements.

CSD 521 Supervised clinical practice in the principles and procedures necessary for assessment of speech and

language disorders with various populations at the Marywood University Speech/Language and Audiology

Clinics. Pre-requisites: Successful completion of CSD 506P with a minimum final grade of B-; updated


CSD 522 Supervised clinical practice at a part time on or off-campus placement site consisting of audiological

evaluations/screenings and aural habilitation/rehabilitation. Pre-requisites: Coursework in audiology and

aural rehabilitation; documentation of 25 hours of direct observation of an ASHA certified Speech-

Language Pathologist and/or Audiologist; updated immunizations and clearances on file; and permission of

the Program Director.

EDUC 597 Supervised clinical practice in the assessment/treatment of speech and language disorders with various

clinical populations at a full time school setting. May be taken in place of CSD 520E. Pre-requisites:

EDUC 502, EDUC 523, EDUC 561, PSY 514 (or UG correlates), as well as any additional courses that

may be added to meet the competencies from the PA Department of Education; successful completion of

CSD 516C or CSD 519I with a minimum final grade of B-; CSD 521 with a minimum final grade of B-;

permission of the Program Director; 25 hours of supervised practicum by a Marywood University Clinical

Supervisor; updated immunizations and clearances on file; CPR certification on file; and completion of

Formative Assessment Manuals per established requirements.

Documentation of professional liability insurance, clearances, CPR certification, and immunizations are on file in the

offices of the Clinic Director or Internship Coordinator.

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Eligibility Requirements and Essential Functions for Students

Marywood University - Department of Communication Sciences and Disorders

Revised Fall 2013

Schwarz, I., Horner, J., Jackson, R., Johnstone, P., Mulligan, M. (2007). Defining essential functions for a diverse student

population. Minneapolis, MN: Council on Academic Programs in Communication Sciences and Disorders.

In order to acquire the knowledge and skills requisite to the practice of speech-language pathology to function in a broad

variety of clinical situations, and to render a wide spectrum of patient care across the lifespan, individuals must have skills

and attributes in five areas: communication, motor, intellectual-cognitive, sensory-observational, and behavioral-social.

These skills enable a student to meet graduate and professional requirements as measured by state licensure and national

certification. Many of these skills can be learned and developed during the course of the graduate program through

coursework and clinical experience. The starred items (*), however, are skills that are more inherent and should be present

when a student begins the program.

COMMUNICATION

A student must possess adequate communication skills to:

• Proficiently read, write, comprehend, and speak the English language.*

• Model target communication skills, unless a clinician’s dialect prevents the effective modeling of a feature. In this case,

other strategies to provide a model should be used. *

• Possess reading and writing skills sufficient to meet curricular and clinical demands in Standard American English.*

• Perceive and demonstrate appropriate non-verbal communication for culture and context.*

• Modify communication style to meet the communication needs of clients, caregivers, and other persons served.*

• Communicate professionally and intelligibly with patients, colleagues, other healthcare professionals, and community or

professional groups.

• Communicate professionally, effectively, and legibly on patient documentation, reports, and scholarly papers required as a

part of course work and professional practice.

• Convey information accurately with relevance and cultural sensitivity.

MOTOR

A student must possess adequate motor skills to:

• Sustain necessary physical activity level in required classroom and clinical activities, including but not limited to the

ability to bend, reach, and stoop in order to move, lift, carry, push, and pull objects such as in the retrieval, using, and

storing of materials and equipment used in evaluations and therapy.*

• Assist with patient care activities such as lifting, wheel chair guidance, and mobility.*

• Respond quickly to provide a safe environment for clients in emergency situations including fire, choking, respiratory

arrest, etc.*

• Access transportation to clinical and academic placements as well as transport self throughout the setting as required.*

• Participate in classroom and clinical activities for the defined workday.*

• Efficiently manipulate testing and treatment environment and materials without violation of testing protocol and with best

therapeutic practice.

• Manipulate patient-utilized equipment (e.g. durable medical equipment to include AAC devices, hearing aids, etc) in a

safe manner.

• Access technology for clinical management (i.e. billing, charting, therapy programs, etc.).

INTELLECTUAL / COGNITIVE

A student must possess adequate intellectual and cognitive skills to:

• Comprehend, retain, integrate, synthesize, infer, evaluate and apply written and verbal information sufficient to meet

curricular and clinical demands.*

• Complete timed, online, and/or other types of examinations or projects in a setting that is acceptable to the program.

• Identify significant findings from history, evaluation, and data to formulate a diagnosis and develop a treatment plan.

• Solve problems, reason, and make sound clinical judgments in patient assessment, diagnostic and therapeutic plan and

implementation.

• Self evaluate, identify, and communicate limits of one’s own knowledge and skill to appropriate professional level and be

able to identify and utilize resources in order to increase knowledge.

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• Utilize detailed written and verbal instruction in order to make unique and independent decisions.

SENSORY/OBSERVATIONAL

A student must possess adequate sensory skills of vision, hearing, tactile, and smell to:

• Visually and auditorily identify normal versus disordered areas (including, but not limited to fluency, articulation, voice,

resonance, respiration characteristics, oral and written language in the areas of semantics, pragmatics, syntax, morphology

and phonology, hearing and balance disorders, swallowing, cognition, and social interaction related to communication).

• Identify the need for alternative modalities of communication.

• Visualize and identify anatomic structures.

• Visualize and discriminate imaging findings.

• Identify and discriminate findings on imaging studies.

• Discriminate text, numbers, tables, and graphs associated with diagnostic instruments and tests.

• Acutely hear differences in speech impairments and modify therapy as required.

• Recognize when a client’s family does or does not understand the clinician’s written and or verbal communication.

BEHAVIORAL/ SOCIAL

A student must possess adequate behavioral and social attributes to:

• Display mature empathetic and effective professional relationships by exhibiting compassion, integrity, and concern for

others.*

• Recognize and show respect for individuals with disabilities and for individuals of different ages, genders, race, religions,

sexual orientation, and cultural and socioeconomic backgrounds.*

• Conduct oneself in an ethical and legal manner, upholding the ASHA Code of Ethics and university and federal privacy

policies.*

• Maintain general good physical and mental health and self-care in order not to jeopardize the health and safety of self and

others in the academic and clinical setting.*

• Adapt to changing and demanding environments (which includes maintaining both professional demeanor and emotional

health).

• Manage the use of time effectively to complete professional and technical tasks within realistic time constraints.

• Accept appropriate suggestions and constructive criticism and respond by modification of behaviors.

• Dress appropriately and professionally.

Please note: Students in the department must meet all of the Eligibility Requirements and Essential Functions set forth

above on a continuing basis. A student may be denied permission to continue in the program should the student fail at any

time to demonstrate the required Eligibility Requirements and Essential Functions even after being given reasonable

accommodations established in conjunction with Marywood University’s Office of Student Support Services. These

requirements/functions are in addition to the Knowledge and Skills Acquisition (KASA) standards that are required by the

American Speech-Language-Hearing Association’s Council for Academic Accreditation.

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THE PRACTICUM SEQUENCE: AN OVERVIEW

The clinical practicum has been integrated into the undergraduate and graduate programs to allow students to develop

clinical sensitivities and strategies in conjunction with academic coursework.

UNDERGRADUATE PRACTICUM

1. Mandatory prerequisites prior to the initiation of clinical practicum are:

A. Twenty-five (25) observation hours of ASHA certified SLPs /AUDs

B. A QPA of 3.25 overall and within the major

C. Permission of Department Chairperson

D. Completion of CSD 361 Clinical Methods and Processes or CSD 362 Clinical Methods and Processes in

Audiology with a minimum grade of B-. If this minimum grade is not achieved, a remediation plan will be

implemented prior to transition into a clinical practicum.

E. Proof of Immunizations (information to follow)

F. Proof of Child Abuse and Criminal Record Clearances

G. Proof of HIPAA training

H. Completion of Speech-Hearing Screening

2. If all pre-requisites are met and maintained:

a. Undergraduate CSD majors typically register for Clinical Practicum during the summer semester of the

transition to the professional phase: CSD 468A.

b. Undergraduate CSD majors pursuing audiology would register for Clinical Practicum in Audiology, 470A

and 470B.

GRADUATE PRACTICUM

1. Graduate students majoring in speech-language pathology register for five consecutive semesters of speech-

language practicum: CSD 516A, CSD 516B, CSD 516C, CSD 519I, CSD 520E. If a graduate student elects to

pursue Teacher Certification, EDUC 597 may be substituted for CSD 520E. A minimal final grade of B- (or

Satisfactory rating in the case of EDUC 597) as well as the permission of the Program Director are required in

order to advance to the next practicum experience. Documentation of twenty-five (25) observation hours of ASHA

certified SLPs/ AUDs, as well as proof of immunizations (information to follow), child abuse/criminal record

clearances, HIPAA training, and completion of a speech-hearing screening are required prior to starting the

practicum sequence in addition to completion of Formative Assessment Manual per established requirements.

2. To meet ASHA certification requirements for CCC/SLP a diagnostic practicum is

required at the graduate level: CSD 521. Refer to Diagnostic Practicum Procedures Handbook for detailed

information regarding diagnostic practicum policies.

3. Graduate students are also required to take CSD 522, an audiology/aural rehab

practicum to meet ASHA certification requirements in the minor area of study (i.e., Audiology). Clinical

assignments may be on and/or off campus. Students will be supervised according to ASHA standards by ASHA-

certified audiology clinical supervisors.

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CLINICAL EDUCATION GOALS AND OBJECTIVES

The clinical practicum experiences are designed to meet the following goals and objectives:

1. Understand and critically evaluate theoretical principles and clinical methodologies in the screening, evaluation,

treatment, and management of speech, language, voice, fluency, swallowing, and hearing disorders across the lifespan.

2. Provide clinical services through a variety of service delivery models (e.g., individual, group, etc.) and across a variety

of professional settings (e.g., community clinics, private practice, schools, hospitals, skilled nursing homes,

rehabilitation agencies, and university).

3. Develop sensitivity towards cultural and linguistic individual differences when providing clinical services.

4. Develop sensitivity towards not discriminating on the basis of race/ethnicity, religion, gender, age, sexual preference,

or disability in the provision of clinical services.

5. Integrate and apply information from related disciplines (e.g., psychology, medicine, physical and occupational

therapy, nursing, social work, and regular and special education) to the screening, evaluation and treatment of speech,

language, voice, fluency, swallowing, and hearing disorders across the lifespan.

6. Select, administer, and interpret appropriate diagnostic measures (e.g., standardized, criterion referenced, case history,

clinical observations) to assess various types and severities of speech, language, voice, fluency, swallowing, and

hearing disorders across the life span.

7. Design, implement, and evaluate appropriate intervention plans to treat various types and severity of speech, language,

voice, fluency, swallowing, and hearing disorders across the life span.

8. Prepare appropriate clinical documentation (e.g., diagnostic reports, treatment plans, SOAP notes, therapy progress

reports, etc.) for long-term and short-term client management.

9. Use instrumentation and other current technologies to assess and treat various communication disorders.

10. Incorporate relevant and current research findings with the clinical practice of speech-language pathology to support

clinical decisions and treatment efficacy.

11. Conduct effective parent/caregiver interviews to obtain pertinent information to apply to the assessment-intervention

process.

12. Disseminate appropriate and relevant information to clients, their family members, caregivers, and other professionals

using effective communication skills and strategies in a timely manner.

13. Develop the interpersonal skills needed to interact and effectively relate to clients, their families, caregivers, peers, and

other professional team members.

14. Develop the awareness, skills, and techniques to engage in self-evaluation and self-monitoring of clinical skills and

professional behaviors.

15. Implement professional skills related to infection control and universal precautions.

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DIRECTED CLINICAL OBSERVATIONS

Students are required by ASHA to observe a minimum of 25 hours of therapy/diagnostics conducted by ASHA-certified

speech-language pathologists and audiologists. Exception will be given to students clinicians that are pursuing an

advanced degree in Audiology. For these individuals observations from both an ASHA certified or AAA certified

Audiologist will be accepted. Directed clinical observations must be completed prior to the student enrolling in any

practicum experience. These directed observations are designed to provide students with valuable exposure to the clinical

process. Generally, some of the required hours are incorporated into academic coursework at the undergraduate level.

Undergraduate and graduate students will be required to provide documentation of this observation experience prior to the

start of any clinical experience on campus. Students involved in directed clinical observations must complete a Therapy

Observation Form for each session observed and then log the observed sessions onto the appropriate Observation Hours

Log Sheets. Observation hours will then be summarized onto a summary form. A sample of these forms follows.

IMMUNIZATIONS AND CLEARANCES

Prior to working with clients, proof of immunizations and child abuse/criminal record clearances are required. The

information will be reviewed with clinicians prior to the start of the clinical semester (e.g., Undergraduate students will be

informed of these requirements during the spring semester of their junior year while graduate students will be initially

informed via a contact letter from the Graduate Program Director in the summer prior to starting the program). Students

are required to hand in to the Clinic Director and update (as needed) proof of immunizations, including PPD, Tetanus,

Hepatitis B, Varicella, and MMR vaccinations as well as child abuse and criminal record clearances.

CLINICAL METHODS AND PROCESSES COURSEWORK

Undergraduate student clinicians will register for CSD 361: Clinical Methods and Processes, a three credit course to be

taken prior to clinical practicum. Undergraduate student clinicians that are pursuing a further degree in Audiology will

register for CSD 362: Clinical Methods and Processes in Audiology. These courses are designed to develop principles,

methods, and procedures necessary for the development of clinical competencies required for a positive transition into the

entry-level clinical practicum experience.

Graduate student clinicians will register for CSD 518P Advanced Clinical Methods and Processes: Independent Study, a

one credit course to be taken within the first week two weeks of the clinical semester. This seminar will discuss principles,

methods, and procedures necessary for the development of clinical skills and competencies required for entry level into the

profession. Graduate students who were Marywood CSD undergraduates and who successfully passed CSD 361 will have

this requirement waived. Clearances may be required to be updated yearly for some off campus placements, and additional

immunizations may be required.

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Immunization/Drug Testing Policy

(Effective Spring 2014)

All students, prior to working with clients during practicum experiences, must provide proof of immunizations. Those who

are not immunized pose a significant public health risk to their patients/clients, peers/co-workers, and themselves. Further

explanation of this policy, with specific due dates of immunizations, will be presented during CSD 361: Clinical Methods

and Processes and CSD 518P: Independent Study in Clinical Methods and Processes. Information will also be presented,

as needed, at semester cohort meetings.

1. Students will have their family physicians complete the Department of Communication Sciences and Disorders

Immunization Record form and submit it to the Clinic Director and/or Internship Coordinator.

2. All students must provide proof of the following immunizations:

Measles, Mumps, Rubella (MMR) – 2; Titers as necessary

Hepatitis B – 3 or in process

Tuberculin (TB/PPD) Skin Test – 1; Off-campus sites require a 2-step TB/PPD; Chest x-ray reports are

always required when results are positive

Tetanus – 1 valid within 10 years

Varicella – 1 or documentation of disease

Additional – As required by off-campus sites and/or changes to this Immunization Policy

3. Students must update immunizations as necessary and provide proof of said updates to the Clinic Director and/or

Internship Coordinator.

4. Students should be aware that drug testing plus additional immunizations (e.g. influenza) may be required as part

of an off-campus practicum experience.

5. Students who choose to not complete the required immunizations and/or drug testing must sign the

Immunization/Drug Testing Waiver form. Signing the waiver indicates that students understand they may not be

able to complete any/all required practicum experiences. Students further understand that practicum experiences

are required components necessary to complete the Master of Science degree in Speech-Language Pathology and

ultimately become certified by the American Speech-Language-Hearing Association.

6. Students who choose to waive immunization/drug testing requirements are responsible for their own educational

outcomes. The Department of Communication Sciences and Disorders does not take responsibility for a student

who is unable to graduate from the program and ultimately become a certified speech-language pathologist based

on their decision to not complete the required immunizations/drug testing.

7. Unless otherwise indicated by a student in writing, signature of the Manual Agreement Form where this policy is

printed indicates that students give permission to the Department of Communication Sciences and Disorders to

release any/all immunization-related/drug testing information to sites where practicum experiences will take place.

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Immunization/Drug Testing Waiver

Effective Spring 2014

I am requesting a waiver for completion of the following immunizations and/or drug testing (please check all that apply):

Measles, Mumps, Rubella (MMR)

M M R Titers (please circle as applicable)

Hepatitis B

Tuberculin (TB/PPD) Skin Test

2-step TB/PPD

Chest x-ray report based on a positive TB/PPD

Tetanus

Varicella

Drug Testing

Other (please indicate)

By signing this waiver I understand that I may not be able to complete any/all of my required practicum experiences. I

further understand that practicum experiences are required components necessary to complete the Master of Science degree

in Speech-Language Pathology within the Department of Communication Sciences and Disorders and ultimately to become

certified by the American Speech-Language-Hearing Association. Finally, I understand that I am responsible for my own

educational outcomes and that the Department of Communication Sciences and Disorders is not responsible for me being

unable to graduate from the program and ultimately become a certified speech-language pathologist based on my decision

to forgo completion of required immunizations/drug testing.

Student Clinic Director or Internship Coordinator

Date Date

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MARYWOOD UNIVERSITY

DEPARTMENT OF COMMUNICATION SCIENCES AND DISORDERS

SPEECH/LANGUAGE CLINIC

Therapy Observation Form

Client(s): Observer:

Age(s): Observer's Academic Advisor:

Disorder: Place of Observation:

Behavioral Objectives:

Clinician's

Date: Time: Signature:

And/or

Supervisor’s

Signature

ASHA #:

1. Describe the atmosphere of therapy (room set-up, positioning of clinician/client, etc.)

2. What materials are used that help achieve the goal of therapy? (Variety, interest level, age level, etc.)

3. How does the clinician begin the session? (Review home assignment; review previous therapy tasks, etc.) How does the

clinician explain the goal to the client?

4. Describe how the clinician presents the tasks, including demonstrations and models.

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5. Describe modifications made according to the client's responses.

6. Describe reinforcement used. (Verbal, non-verbal, reinforcement schedule, etc.)

7. How does the clinician score responses and progress?

8. Describe how the clinician maintains control of the session. (Behavior, management, etc.)

9. Describe any carryover activities.

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MARYWOOD UNIVERSITY DEPARTMENT OF COMMUNICATION SCIENCES AND DISORDERS


Group Therapy Observation Form

Revised 9/2015

Group Type: Observer:

Age(s): Observer's Academic Advisor:

Place of Observation:

Therapy Objectives

Clinician(s)

Date: Time: Signature:

And/or

Supervisor

Signature

ASHA#:

1. Describe the atmosphere of therapy (room set-up, positioning of clinician/client etc.)

2. How does the clinician begin the session? (Review home assignment; review previous therapy objectives,

etc.) How does the clinician explain the goal(s) to the client?

3. What materials are used that help achieve the goal of therapy? (Variety, interest level, age level, etc.)

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4. Describe how the clinician presents the tasks, including demonstrations and models.

5. Describe modifications made according to the client's responses.

6. Describe reinforcement used. (Verbal, non-verbal, reinforcement schedule, etc.)

7. Describe how the clinician maintains control of the session. (Behavior, management, etc.)

8. Describe any carryover activities.

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MARYWOOD UNIVERSITY


AUDIOLOGY CLINIC

Audiology Observation Form

Client Initials: ___________________

Observer: _____________________________________________

Client Age: _____________________

Academic Advisor: _____________________________________

Diagnosis: ______________________

Audiologist Signature: ___________________________________

Date: __________________________

ASHA or AAA # ______________________________________

Time Observed: __________________ Facility: ______________________________________________

Goals of Service/Reason(s) for Appointment:

Method(s):

Recommendation(s) for follow up:

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Marywood University

Department of Communication Sciences and Disorders

Observation Hours Log Sheet

(Revised 7-1-08)

Name:__________________________________

Please use the following codes for age of client and refer to the codes when filling in the minutes for the type of treatment observed:

Age of Client -- P (Preschool – Birth to 5 years), S (School Age – 6 to 18 years), A (Adult – 19 to 69 years), and G (Geriatric – ≥ 70 years)

Type of Treatment -- A (Articulation), F (Fluency), VR (Voice & Resonance), RE (Receptive & Expressive Language), S (Swallowing), CC (Cognitive

Communication), SC (Social Communication), AC (Augmentative/Alternative Communication), H (Hearing), ST (Staffing & Counseling)

Date Facility Where

Observation Took Place

Age of

Client

Type of Treatment

(Please indicate the number of minutes observed)

Student and Supervisor (on campus)

or ASHA Certified Clinician (off-

campus)

ASHA #

A F VR RE S AC SC CM H ST

Clinic Director: Total Hours:

ASHA #:

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Marywood University


Observation Hour Summary Form

Name

Preschool (Birth – 5 years) Adult (19 – 69 years)

Articulation

Minutes Hours

Articulation

Minutes Hours

Fluency Fluency

Voice &

Resonance

Voice &

Resonance

Receptive &

Expressive

Language

Receptive &

Expressive

Language

Swallowing Swallowing

Cognitive

Communication

Cognitive

Communication

Social

Communication

Social

Communication

Augmentative/Alternative

Communication


Communication

Hearing Hearing

Staffing &

Counseling

Staffing &

Counseling

School Age (6 – 18 years) Geriatric ( ≥ 70 years)

Articulation

Minutes Hours

Articulation

Minutes Hours

Fluency Fluency

Voice &

Resonance

Voice &

Resonance

Receptive &

Expressive

Language

Receptive &

Expressive

Language


Cognitive

Communication

Cognitive

Communication

Social

Communication

Social

Communication


Communication


Communication

Hearing Hearing

Staffing &

Counseling

Staffing &

Counseling

____________Total Minutes

Total Hours

Clinic Director’s Signature Date

ASHA #

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CLINICAL EDUCATION

SPEECH-LANGUAGE THERAPY PROCEDURES AND CLINICAL DOCUMENTATION

1. Student clinicians will be assigned a specific number of clients each semester based on current level of experience and

client availability. As the Marywood University Speech/Language Clinic provides an ongoing community service;

additional clients may be assigned to student clinicians during the course of a semester.

On the first day of the semester, student clinicians will receive their client assignment(s). Generally, undergraduate

students (UG) will receive one to two clients and graduate students (GRAD) will receive at least two clients with an

additional assignment(s) made during the semester.

2. Client files are kept in a file cabinet in the secured computer area of the Student Preparation Room: McGowan 1052,

ID card access is required to enter the computer area.

CLINIC FILES ARE NOT TO BE REMOVED FROM THE CLINIC AREA AT ANY TIME with the exception of

supervisor weekly meetings. Students are expected to follow the Confidentiality Policy and Procedure, which can be found at

the end of this manual.

3. Review the client’s file primarily focusing on the most recent therapy progress and/or diagnostic report. Write the Initial

File Review and make an appointment with your clinical supervisor.

4. Be prepared to discuss the Initial File Review with your supervisor at your initial mandatory meeting. In addition, your

anticipated plan of treatment will be discussed at this initial meeting (i.e. behavioral objectives).

5. A mandatory weekly meeting must be scheduled between the supervisor and student clinician. The purpose of this

meeting is to discuss client’s progress, course of treatment, and the clinician’s growth and development. A mutually

agreeable meeting time must be established during the first week of the semester for these mandatory meetings.

Students are required to bring the Client File to all supervisory meetings.

6. Based on the information compiled in the approved Initial File Review (kept in Student’s Work Folder- Section IV of

the client file), a Weekly Treatment Plan should be developed.

7. Student clinicians must submit a Weekly Treatment Plan for each client to their supervisor. The supervisor must have

adequate time to either make suggestions for revisions or approve the plan prior to the therapy session. If a treatment

plan requires revisions, the student clinician must have ample time to correct the plan, re-submit it, and have the

supervisor approve it prior to the therapy session. Revisions following the first draft should have a 24-hour turnover. It

is both the student clinician’s and the supervisor’s responsibility to establish appropriate timelines. Approved Weekly

Treatment Plans are kept in the Student’s Work Folder (Section IV of the client file).

8. SOAP Notes are to be completed monthly during the semester, with due dates established and reviewed at the initial

semester clinic meeting. Data is taken from the Daily Outcome Data Log and concisely summarized into SOAP note

format. The completed and approved SOAP Notes are placed in the client’s file (Section III).

9. Discuss results of the semester’s therapy with your supervisor and prepare for the family conference to be held during

the last therapy session.

10. Write the Therapy Progress Report. Follow the specified time lines for submitting the initial draft and final letter-

perfect copy to your Clinical Supervisor. The final signed report is placed in the client’s file (Section III).

20

11. All students should familiarize themselves with the organization of the client’s file. (See Client File Sequence Form.)

Section IV of the client’s file is the Student’s Work Folder, which contains the following:

A. Client Assignment

B. Initial File Review

C. Weekly Treatment Plans

D. Session Evaluation Forms

E. Rough Drafts of Clinical Documentation

F. Clinical Supervisor’s Written Feedback (optional)

G. Clinical Hour Tracking Form(s)

12. Documentation of all client contacts is placed on the Communication Log Sheet. (Front Cover of Client’s File).

Students and supervisors are reminded to initial each entry made on the communication log sheet.

13. Attendance sheets will be maintained for all clients. At the end of the semester, the original attendance sheet will be

forwarded to the Clinic Director, only after being initialed by the clinical supervisor.

14. All clinical documentation must be received, approved, and signed by the clinical supervisor by the date specified.

Students not in compliance with the specified due date will receive a 5 point reduction in their final clinic grade.

15. Several clinic forms (weekly treatment plan, session evaluations, data log, and initial file review) are available on the

department issued flash drive. Once work is completed, all files MUST BE SAVED ONTO A DEPARTMENTAL

FLASH DRIVE AND NOT THE C DRIVE SECONDARY TO PATIENT CONFIDENTIALITY. At the end of the

semester, the clinical supervisors will collect all flash drives and client specific information will be deleted. Please note

that printing of clinical information can only be done in McGowan 1052.

16. At the end of the semester the student clinician and supervisor will meet to review clinical documents and hours,

discuss grade for clinical practicum, complete formative assessment manuals (graduate students) and organize the

client’s chart. The Student’s Work Folder will be removed from the client’s file. The folder, with the exception of the

supervisor’s written feedback and clock hour tracking forms, will be filed in a separate area by the clinic staff. The

clock hour forms will be given to the Clinic Director along with the student’s grade and supervision log, which was

completed by the student’s supervisor. Student clinicians are also required to complete a supervisor survey and submit

to the Clinic Director. Failure to complete all documentation, organize the client chart, and return all clinical

property (i.e. flash drives, therapy materials, etc.) by the date specified in the semester clinic memo will result in

an incomplete for the course, which if not rectified by a date specified by the clinic director, will change to an

“F” for the final semester grade.

AUDIOLOGY/AURAL REHABILITATION PRACTICUM PROCEDURES

1. Student clinicians will receive their audiology/aural rehabilitation assignments from the Clinic Director. Typically,

assignments will last approximately 15 hours in total (2 days per week for a set number of hours per day), but may

vary in terms of specifically set hours depending on the student and/or audiologist schedules.

2. Assignments may be on or off campus based on the availability of scheduled ASHA certified and PA licensed

audiologists.

3. At the end of the practicum, the student and supervisor will meet to review clinic hours and supervision logs,

discuss the grade for the practicum experience, and complete applicable sections of the formative assessment

manual. Supervisors will then submit hour summary sheets (with tracking sheets attached), supervision logs, at

least 4 written observations of the student, and grades to the Clinic Director. Students are also required to complete

a supervisor survey and submit to the Clinic Director. Failure on the part of any student to complete any

audiology/aural rehabilitation practicum requirement will result in an incomplete for the course, which if

not rectified by a date specified by the Clinic Director, will change to an “F” for the final semester grade.

21

CLINICAL PRACTICUM FORMS

This section of the Clinic Handbook provides samples of the forms for therapeutic intervention used in conjunction with

undergraduate and graduate clinical practicums.

CLIENT FILE SEQUENCE

Front Cover: Communication Log Sheet

Section I: Identifying Information

1. Attendance Sheet

2. Clinical Services Referral Form

3. Case History

4. Release Forms

a. Release of Information To

b. Release to Obtain Information From

c. Authorization for Exchange and Use of Clinical Information

(Audio-Visual Release Form)

5. Clinic Specific Forms (Attendance Policy, Dietary Policy, etc.)

6. Reports from other agencies/correspondence

7. Doctor’s Prescription

Section II: Diagnostic Information

1. Diagnostic Report(s)

2. Original test and language sample/narrative forms

3. Audiological Evaluation Report(s)

Section III: Treatment Information (Organized by Semester)

1. Therapy Progress Reports

2. SOAP Notes

3. Daily Outcome Data Log Forms

Section IV: Student’s Work Folder

1. Client Assignment

2. Initial File Review

3. Weekly Treatment Plan

4. Session Evaluation Forms

5. Rough Draft of Clinical Documentation

6. Clinical Supervisor’s Written Feedback (Optional)

8. Clinical Hour Tracking Form(s)

Student clinicians are expected to maintain the appropriate order of clinical documentation in the client’s files. All

documentation should be arranged with the most recent information towards the top of the section.

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MARYWOOD UNIVERSITY


SPEECH/LANGUAGE and AUDIOLOGY CLINICS

Communication Log Sheet

Name:

Date Notes

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MARYWOOD UNIVERSITY



ATTENDANCE SHEET

Spring 2014

Client’s Name: Date of Birth:

Diagnosis:____________________________ Clinician:

Telephone No.: Supervisor:

Days: M T W TR F Time:

(please circle)

Please circle each session attended or mark the following if the session was missed:

Cancellation= CX No Show= NS

May

June

July

22 3 1

23 4 2

28 5 3

29 6 8

30 10 9

11 10

12 11

13 15

17 16

18 17

19 18

20 22

24 23

25 24

26 25

27

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MARYWOOD UNIVERSITY



Clinical Services Referral*

Client’s Name: Date:

Client’s Address:

D.O.B. Age: Sex: Male Female

Medical DX: S/L DX:

Contact Name: Telephone #:

Referral Source: Physician:

Day preference: (circle) Monday Tuesday Wednesday Thursday

Time preference: (circle) 9:00 10:00 11:00 1:00 2:00 3:00 4:00

Reason for Referral: Speech/Language Fluency Voice

Other (specify):

Additional comments:

Case History Form Sent: Date Returned:

Clinical Recommendation:

Semester: Estimated First TX Date

Signature:

Revised Fall 2015

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MARYWOOD UNIVERSITY


AUDIOLOGY CLINIC

Clinical Services Referral - Audiology

Client’s Name: Date:

Client’s Address:

D.O.B.: Age: Sex: Male Female

Medical DX: ICD Code:

Contact Name: Telephone #:

Referral Source: Physician:

Insurance: First Priority Private Pay

Geisinger

Other

Reason for Referral: Hearing Aid Hearing Test ALD

Other (specify):

Additional Comments:

Clinical Recommendation:

Semester:

Signature:

Forward copy to department assistant

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MARYWOOD UNIVERSITY



Case History (Child)

The following questions are asked so that we may better understand your child. Please read them carefully and

answer as fully as possible. If you are not sure how to answer some of the questions, please tell us and we will discuss

them. If you need more space, use the back of the sheet.

Please Print

Date __________________________________

Your child’s full name _______________________________________Date of Birth _____________________

Address __________________________________________________________________________________

(Number) (Street) (City) (State) (Zip)

Telephone __________________________ School (Preschool)_________________________Grade _______

Name of person completing our questionnaire

____________________________________________________Relationship to child ___________________

Family Physician_______________________________________

Address of Physician _____________________________________________________________________

HISTORY OF PREGNANCY AND BIRTH

1. Is mother Rh negative? __________ Were there illnesses during her pregnancy with this child?_______

Did mother have to stay in bed? __________ Take medications (other than vitamins)? __________

Any complications during pregnancy?

If yes to any of these please explain: ________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

2. Length of pregnancy _______________________Was labor very long or especially short? ___________

If yes, estimate time _________________ Was the birth of this child without complication? ______________

Any notable trauma? __________ If so, please explain: ____________________________________________

27

_________________________________________________________________________________________

What was the child’s weight at birth? __________________________________________________________

3. Did the child have any trouble breathing after birth? ______________ Was the child kept in an

incubator after birth? __________ Why? ________________________________________________________

Did the child look blue or yellow after birth? _________ How long? __________________ Did the

child come home from the hospital with the mother? ___________If not, why? _________________________

_________________________________________________________________________________________

4. Is this child adopted? ____________ How old was he/she when adopted? ________________________

DEVELOPMENTAL HISTORY

1. At what age did the child sit alone? ______________Crawl? ___________Walk by himself? _________

Was this child very active as a baby? __________________________________________________________

2. Was feeding the child a problem? ____________Why? _______________________________________

When was he/she taken off the bottle or breast? ________________________ Was this a problem? ________

3. Is the child a fussy or “picky” eater now? _______Does he seem to have any trouble swallowing? _____

Chewing? ___________ Does the child eat with a spoon? __________ Fork? ___________ Both? ________

4. Was toilet training a problem? _____________ When was the child completely trained? ____________

Does the child wet the bed at night now? __________ How frequently? ______________________________

Does the child wet or soil himself during the day? __________ How often? ___________________________

5. Does the child dress himself completely? __________ Partially? __________

Does he/she button? ________ Tie shoes? ___________

6. Does the child fall frequently? __________ How well can he/she climb? ______________________

Throw a ball? __________ Ride a tricycle? __________Ride a two wheel bike? _________Run? __________

7. Which hand does the child use to eat with? _________________ Draw or write? _________________

Throw a ball? __________________________

28

MEDICAL HISTORY

1. Has the child been back in the hospital since birth? _______________ If so, explain (operations,

accidents, etc.), and give age and date of occurrence. _____________________________________________

________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

2. Has the child had other serious illnesses? _________________ If so, describe. ___________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

3. Has the child ever fainted or passed out? _____________ Has he ever had a convulsion? ___________

How many? ___________ Describe _____________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

4. Does the child have any problem hearing? __________ Has he/she had ear infections, ear drainage, ear

aches, ear surgery, history of familial hearing loss? ____________ If yes, explain.______________________________

_______________________________________________________________________________________________

5. Does the child see normally? __________ Does he/she wear glasses? ______________

6. Is this child allergic to anything? __________ If yes, what? __________________________________

7. Does the child take any medicine regularly except vitamins? ____________ If so, what and why?

__________________________________________________________________________________________

8. Does he/she seem to display an “overly” active behavior or lack of attention? _____________________

9. Has the child ever been seen by a specialist? ___________ If so, describe the circumstances _________

29

SPEECH AND LANGUAGE DEVELOPMENT

1. Was the child very quiet as a baby (did not babble and coo as most babies)? _____________________

Did he/she cry excessively? __________________________________________________________________

2. What is the primary language spoken in the home?__________________________________________

3. How old was the child when he began to say words? _______________________________ How old

was the child when he/she began putting 2 or 3 words together in a phrase? _____________________________

4. How much does the child talk now? ______________________________________________________

5. How much of this speech can parents understand? All? ________ Most? _______ Some? ________

How much can other adults understand? All? _________ Most? _________ Some? _________ None? _____

6. How much does the child use gestures to help others understand? _______________________________

_________________________________________________________________________________________

7. Has the child learned to say nursery rhymes? _________ Prayers? __________ Sing songs? _________

8. Do parents feel the child stutters or stammers? _____________________________________________

If so, when did this begin? Is the child aware?

9. Does child’s voice sound like other children’s voices? _________ If no, describe: Very soft _________

Very loud __________ Hoarse ___________ Nasal ____________ Other _______________________

10. Does the child have any reading difficulties?________________________________________________

11. Have parents done anything to help child with his/her speech? _________ If so, explain _____________

_________________________________________________________________________________________

12. Did the speech learning ever seem to stop for a period? __________ When? _____________________

13. Has there been a change in his/her speech in the last six months?_______________________________

14. Has he/she ever talked better than he/she does now? ____________ When? ______________________

15. What is the self reaction to his/her speech? ________________________________________________

30

FAMILY

1. Are parents now separated? ______________ Divorced? ______________ If so, how old was the child

when this occurred?___________________

2. Father’s name _______________________________________________________ Age ___________

Occupation ______________________________________ Level of education ________________________

3. Mother’s name ______________________________________________________ Age ____________


If mother works, who takes care of the child? ____________________________________________________

How old was the child when mother went to work? _______________________________________________

4. Give names and ages of other children in the family._________________________________________

_________________________________________________________________________________________

5. Are there relatives, on either side of the family, who have had:

_____ Trouble speaking clearly or who have been late in learning to talk?

_____ Trouble with their hearing?

_____ Trouble learning in school so that they left school or failed several grades, or who have had real trouble

learning to read?

_____ Problems like epilepsy, intellectual disabilities, cerebral palsy etc. If so, describe problem.

ADDITIONAL INFORMATION

1. Describe this child’s behavior (i.e. quiet, moody, independent, etc.) _____________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

2. Does the child enjoy having books read to him or read by himself/herself? ________________________

3. What are the child’s interests/favorite activities? ____________________________________________

31

4. Does the child play well alone? ______________ With younger children? _______________

With older children? _________________ With his brothers and sisters? _________________

What do you feel is this child’s problem?___________________________________________________

Please list any doctors, clinics, hospitals or any other agencies plus dates where your child has been evaluated.

EDUCATIONAL HISTORY

1. Preschool __________________Public School ______________Private School _________________

2. Has the child had any previous speech or language therapy? __________ When? __________________

Where? __________________________________________________ Please describe the problem or therapy.

_________________________________________________________________________________________

3. Is the child in a mainstreamed in a regular education classroom? Is the child in a

learning support classroom? Does the child have an aide while at school?

32

MARYWOOD UNIVERSITY



Case History (Adult)

Please Print Date

Name

(Last) (First) (Middle)

Address


Date of Birth Telephone

(Month) (Day) (Year) (Area Code) (Number)

Name of Person Completing this Questionnaire

Relationship to Client

Family Physician

Address of Physician


Name of person who referred you to this Clinic

Why has an appointment been requested?

MEDICAL HISTORY

List illnesses, injuries, childhood diseases, operations, and medications. Please give dates and length of disability.

Include any physical handicaps, prolonged fevers, convulsions, etc.

(Illness, injury, operation, or medication) (Date)

Do you feel you have a hearing problem? No Yes

If yes, explain

33

Do you have a history of hearing loss, ear infections, ear drainage, ear surgery, history of familial hearing loss?

No Yes If yes, please explain

Do you ever have any difficulty swallowing foods or liquids? No Yes

If yes, explain

Have you ever received therapy for your swallowing difficulty, or utilized any type of compensatory strategies

or diet/liquid modifications to assist in swallowing? No Yes

If yes, please explain

EDUCATION AND SOCIAL HISTORY

Are you retired? Yes_______ No________

If employed, what is your occupation?

How long have you been employed in your present position?

Please indicate the highest level of education you have attained:

Grade School College Graduate

High School Graduate School

College Other

If other, please explain

Please indicate your marital status: Single Married

Divorced Separated

34

Please list names and ages of your children:

Do you reside with anyone? _______ If so, list __________________________________________________

HISTORY OF SPEECH PROBLEM

(To include any speech, language, cognitive, fluency, and voice difficulties)

Native Language: ____________________ Primary language spoken in home:__________________________

Describe your communication problem

The date of onset of the communication problem?

Have you ever been treated for your communication problem? No Yes

If yes, please explain

What have you done to improve your communication problem?

Have your communication skills become better or worse during the past six months?

Under what circumstances, if any, does your communication improve?

35

Are there relatives, on either side of the family, who have had communication difficulties? If so, please explain.

Please list any doctors, clinics, hospitals, or any other agencies where you have been seen for previous therapy.

36

MARYWOOD UNIVERSITY



Accent Modification- Adult Case History

Name: Date:

Address: Home Phone:

Cell Phone:

E-Mail Address: Date of Birth:

Occupation; Employer: _______________ ______

Highest Level of Education Completed:

If a Student, List University and Major:

Marital Status: _______________________________

Name of Spouse or Nearest Relative:

Native Language: _______________________ Primary Language:

1. Please explain why you wish to be evaluated in our clinic?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. What do you hope to gain through using our services?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

3. Have you ever received previous instruction for your speech production and/or language skills? If so, please

include when and where.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

4. When did you begin to study English?

5. How long have you been speaking English?

6. How long have you lived in the United States?

7. How often do you speak English? (e.g. only in class / at work, only occasionally with English speaking peers, etc.)

_____________________________________________________________

37

8. What language do you speak when you are with others from your native country?

______________________________________________________________________________

9. How confident are you in your ability to speak English?

Confident----------------Somewhat Confident----------------Not Confident

5 4 3 2 1

10. How confident are you in your use of English vocabulary?


5 4 3 2 1

11. How confident are you in the use of grammatical structures of standard American English?


5 4 3 2 1

12. How easily is your speech understood by native English speakers?

Easily Understood----------------Usually Understood----------------Not Understood

5 4 3 2 1

13. In what situations, if any, do you have to speak in front of others?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

14. Do you feel like you know the vocabulary needed to adequately express yourself? If no, please explain.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

15. Which English speech sounds are the most difficult for you to produce?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

16. What speaking situations do you feel most confident?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

17. When speaking English, what speaking situations make you most nervous?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

18. Do you have difficulty understanding individuals who speak English as their first language? If yes, please explain.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

38

19. What do you do when a listener does not understand you?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

20. Do you have any medical conditions that may impact your speech and/or language? If yes, please explain.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

21. Do you have any history of hearing loss or hearing deficits? If yes, please explain.

______________________________________________________________________________

______________________________________________________________________________

_______________________

39

MARYWOOD UNIVERSITY



AAC Case History

The following questions are asked so that we may better understand your child. Please read them carefully and

answer as fully as possible. If you are not sure how to answer some of the questions, please tell us and we will discuss

them. If you need more space, use an additional piece of paper.

Please Print

Date _____________________

Your child’s full name __________________________________Date of Birth __________________________

Address___________________________________________________________________________________


Telephone __________________ School (Preschool) ____________________________ Grade __________

Name of person completing our questionnaire ___________________________________________________

Relationship to child _____________________ Family Physician ____________________________________

Address of Physician _______________________________________________________________________

Who is your referral source? __________________________________________________________________

What is the reason for your referral? ____________________________________________________________

List any medical diagnoses: ___________________________________________________________________

When he/she was first diagnosed with that condition? ______________________________________________

With whom does the child live? ________________________________________________________________

What do you hope to accomplish by coming to the Clinic? __________________________________________

__________________________________________________________________________________________

40

COMMUNICATION STATUS

1. How would you describe the child’s current communication ability (indicate using rating scale below)?

1: Almost never 2: Sometimes 3: Frequently

___Is very easy for me to understand when I know the topic of conversation

___Is fairly easy for me to understand when I know the topic of conversation

___Is difficult for me to understand when I know the topic of conversation

___Is very easy for me to understand if I DON'T know the topic of conversation

___Is fairly easy for me to understand if I DON'T know the topic of conversation

___Is difficult for me to understand if I DON'T know the topic of conversation

___Is usually understood by other people who don't know him/her well

___Is usually NOT understood by other people who don't know him/her well

2. Please describe how the child communicates the following:

a) Wants and needs:

___________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

b) Things that happened in the past or will happen in the future:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

c) Gives or asks for information/help:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

d) Protests:____________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

e) He/She communicates during play by:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

f) What other things does he/she do to communicate (e.g. cry, whine, look to something he wants)?

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

g) What gestures does this child make (e.g. pointing, motioning to “come here”, tugging for attention, push you away

to protest?)

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

3. What sounds can the child produce? (e.g. “b”, “duh”, “ah”)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

41

4. How many words are in the child’s vocabulary? ______

5. Can the child consistently produce a word approximation (e.g., always says “ca” for “cup”)

___Yes ___No

If yes, please list these word approximations:

_____________________________________________________________________________________________

_______________________________________________________________________________

6. Can the child write words? __ Yes ___No

7. Can the child copy words? __ Yes ___No

HISTORY OF PREGNANCY AND BIRTH

1. Is mother Rh negative? __________ Were there illnesses during her pregnancy with this child?_______

Did mother have to stay in bed? __________ Take medications (other than vitamins)? __________

Any complications during pregnancy?

If yes to any of these please explain: ________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

2. Length of pregnancy _______________________Was labor very long or especially short? ___________

If yes, estimate time _________________ Was the birth of this child without complication? ______________

Any notable trauma? __________ If so, please explain: ____________________________________________

_________________________________________________________________________________________

What was the child’s weight at birth? __________________________________________________________

3. Did the child have any trouble breathing after birth? ______________ Was the child kept in an

incubator after birth? __________ Why? ________________________________________________________

Did the child look blue or yellow after birth? _________ How long? __________________ Did the

child come home from the hospital with the mother? ___________If not, why? _________________________

_________________________________________________________________________________________

4. Is this child adopted? ____________ How old was he/she when adopted? ________________________

42

DEVELOPMENTAL HISTORY

1. At what age did the child sit alone? ______________Crawl? ___________Walk by himself? _________

Was this child very active as a baby? __________________________________________________________

2. Was feeding the child a problem? ____________Why? _______________________________________

When was he/she taken off the bottle or breast? ________________________ Was this a problem? ________

3. Is the child a fussy or “picky” eater now? _______Does he seem to have any trouble swallowing? _____

Chewing? ___________ Does the child eat with a spoon? __________ Fork? ___________ Both? ________

4. Was toilet training a problem? _____________ When was the child completely trained? ____________

Does the child wet the bed at night now? __________ How frequently? ______________________________

Does the child wet or soil himself during the day? __________ How often? ___________________________

5. Does the child dress himself completely? __________ Partially? __________

Does he/she button? ________ Tie shoes? ___________

6. Does the child fall frequently? __________ How well can he/she climb? ______________________

Throw a ball? __________ Ride a tricycle? __________Ride a two wheel bike? _________Run? __________

7. Which hand does the child use to eat with? _________________ Draw or write? _________________

Throw a ball? __________________________

8. Coordination: ___good ___clumsy

9. Does the child use any of the following? (Check all that apply):

_____Wheelchair ____Walker ____Special Chair

_____Other special equipment (describe)_________________________________________

If a wheelchair is used, please describe the following:

Make: ______________________________________________________

Motorized: _________________________ Manual:_________________________________

Lap Tray Measurements: _____________________________________________________________

43

10. Check all that apply to your child:

_____Eating problems _____Sleeping problems _____Difficulty concentrating

_____Needs a lot of discipline _____Interactive _____Excitable

_____Laughs easily _____Cries a lot _____Difficult to manage

_____Overactive _____Sensitive _____Gets along with adults

_____Stays with an activity _____Makes friends easily _____Happy

_____Irritable _____Easily frustrated _____Attentive

_____Easily distracted _____Memory difficulty _____Difficulty reading

_____Easy going personality _____Rigid personality _____Difficulty attending to tasks

_____Difficulty attending in noisy environments

_____Easily transitions between activities and environments

11. Would the child separate easily for therapy? ____Yes____ No

MEDICAL HISTORY

1. Has the child been back in the hospital since birth? _______________ if so, explain (operations, accidents, etc.),

and give age and date of occurrence. ______________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

2. Has the child had other serious illnesses? _________________ If so, describe. ___________________

__________________________________________________________________________________________

__________________________________________________________________________________________

3. Has the child ever fainted or passed out? ___________ Has he ever had a convulsion? ______________

How many? ___________ Describe ___________________________________________________________

__________________________________________________________________________________________

4. Does the child have any problem hearing? __________ Has he/she had ear infections, ear drainage, ear

aches, ear surgery, history of familial hearing loss? ____________ If yes, explain. ________________________

__________________________________________________________________________________________

5. Is visual acuity a concern? __________ Does he/she wear glasses? ______________

6. Is this child allergic to anything? __________ If yes, what? __________________________________

7. Does the child take any medicine regularly except vitamins? _________ If so, what and why? _______

_________________________________________________________________________________________

44

8. Has the child ever been seen by a specialist? ___________ If so, describe the circumstances _________

___________________________________________________________________________________________

SPEECH AND LANGUAGE DEVELOPMENT

1. Describe how the child babbled and cooed as a

baby_______________________________________________________________________________________

Did he/she cry excessively? If yes, please

explain_____________________________________________________________________________________

2. Does your child effectively communicate in (Check all that apply):

___Asking for wants/needs? ___Getting your attention?

___Labeling people, things, or pictures around him/.her? ___Asking questions?

___Greeting people? ___Asking for help?

___Sharing information/commenting?

*If your child had/ has any ability to verbalize please complete #3-12:

3. How old was the child when he began to say words? _______________________________ How old

was the child when he/she began putting 2 or 3 words together in a phrase? ____________________________

4. How much does the child talk now? ______________________________________________________

5. How much of this speech can parents understand? All? ________ Most? _______ Some? ________

How much can other adults understand? All? _______ Most? _________ Some? ________ None? _________

6. Do parents feel the child stutters or stammers? ______________________________________________

If so, when did this begin? Is the child aware?

7. Does child’s voice sound like other children’s voices? _________ If no, describe: Very soft _________

Very loud __________ Hoarse ___________ Nasal ____________ Other _______________________

8. Have parents done anything to help child with his/her speech? __________ If so, explain ___________

__________________________________________________________________________________________

9. Did the speech learning ever seem to stop for a period? __________ When? ______________________

10. Has there been a change in his/her speech in the last six months?________________________________

45

11. Has he/she ever talked better than he/she does now? ____________ When? ______________________

12. What is the self-reaction to his/her speech? _________________________________________________

AIDED COMMUNICATION

Please complete if your child is using/has used an augmentative system:

1. Has the child in the past, or does he/she currently use an augmentative communication device or any assistive

technology at home, school, and/or private therapy? ____ yes _____no

If he/she has used in the past only, briefly explain why he/she is not currently using/drawbacks:

____________________________________________________________________________________

____________________________________________________________________________________

2. Who evaluated the child for the augmentative communication device or assistive technology?

____________________________________________________________________________________

Name of the device:_______________________________________ Age of the Device:____________

How long has the child been using an augmentative system ?_____________________________

3. Please list all communication systems used in the past and indicate whether the system proved to be successful or

unsuccessful:

System Successful Unsuccessful

___________________________ ____________________ __________________

___________________________ ____________________ __________________

___________________________ ____________________ __________________

4. If your child uses communication boards, books, devices to communicate please provide additional information

regarding:

Symbol type:

___Text

___PECS (Picture Exchange Communication System)

___Mayer-Johnson PCS

___Photographs

___Other; Describe:

Number of symbols per page/display: _____

Presentation:

___Removable icons

___Static grid

Access:

___Point

___Symbol exchange

___Other; Describe: _______________________________________________________

46

5. He/she primarily uses the augmentative system:

___Imitatively

___In response to questions

___In response to commands (e.g., “Show me what you want.” )

___Spontaneously (I.E., on his/her own initiative without any cueing)

6. Environments where device is used (Check all that apply)

___Structured school activities

___In therapy

___At home during structured tasks

___Most of the time spontaneously

___All of the time spontaneously

7. Are modifications necessary to accommodate visual impairments? ___Yes ___No

8. Can the child combine symbols to form a message? ___Yes ____No If yes, how many? _________

9. Augmentative system use: (Check all that apply)

___Initiates communication with the system

___Uses the system to ask and answer questions

___Needs direction/prompting

___Single key is used to express a full message

___Able to participate in a conversation using a device

___Functional spelling skills

___Uses system as a backup to speech

___Makes wants/needs known with device

___Navigates device with assistance

___Navigates independently

___Explores the device but does not use functionally

10. Parents knowledge of device:

___New device, no experience

___Basic skills (on/off, navigation)

___Can program

___Advanced programming

11. Access: (Check all that apply)

___Direct selection (touchscreen, keyboard

___Keyguard (yes/no)

___Scanning: Type of switch:___________ Type of scanning:_____________________________

___Joystick

___Headmouse

___Eyegaze ___Other Please describe:___________________________________________

12. In your opinion which can your child most easily control the movement of:

___Eyes ___Head ___Foot ___Right hand ___Left hand

13. Does he/she use a splint? ___Yes ___No If yes, where?

________________________________________________

47

FAMILY

1. Are parents now separated? ______________ Divorced? ______________ If so, how old was the child

when this occurred?___________________

2. Father’s name _______________________________________________________ Age ___________


3. Mother’s name ______________________________________________________ Age ____________


If mother works, who takes care of the child? ____________________________________________________

How old was the child when mother went to work? _______________________________________________

4. Give names and ages of other children in the family._________________________________________

_________________________________________________________________________________________

5. Are there relatives, on either side of the family, who have had:

_____ Trouble speaking clearly or who have been late in learning to talk?

_____ Trouble with their hearing?

_____ Trouble learning in school so that they left school or failed several grades, or who have had real trouble

learning to read?

_____ Problems like epilepsy, intellectual disabilities, cerebral palsy etc. If so, describe problem.

ADDITIONAL INFORMATION

1. Describe this child’s behavior (i.e. quiet, moody, independent, etc.) _____________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

2. Does the child enjoy having books read to him or read by himself/herself? ________________________

48

3. What are the child’s interests/favorite activities? ____________________________________________

4. Does the child play well alone? ______________ With younger children? _______________

With older children? _________________ With his brothers and sisters? _________________

What do you feel is this child’s problem?___________________________________________________

Please list any doctors, clinics, hospitals or any other agencies plus dates where your child has been evaluated.

5. Do you have a working computer your child uses at home? ____Yes ___No

6. How frequently does your child use the computer? ____Never ___Occasionally ___Daily

Purpose of the computer use: (check all that apply)

___Educational tool

___Reward

___Communication

___Play games

7. How does your child access the computer? (Check all that apply)

___Mouse

___Adaptive access (E.g., IntelliKeys, touch window, etc.)

___Keyboard

___My child does not independently access the computer

EDUCATIONAL HISTORY

1. Preschool __________________Public School ______________Private School _________________

2. Has the child had any previous speech or language therapy? __________ When? __________________

Where? __________________________________________________ Please describe the problem or therapy.

_________________________________________________________________________________________

3. Current Placement/Grade: _____________________________________________

4. Does the child have an aide with him/her in school?

___Yes ___No

If yes, does this aide work with your child?

_______ All day _______ About half of the day _______ Less than half of the day

_______ Just this child _______ Several children _______ The whole class

49

MARYWOOD UNIVERSITY



Authorization for Release of Information

Date

I hereby give permission to the Marywood University Speech/Language Clinic to release information on

To:

Signature


50

MARYWOOD UNIVERSITY



Authorization for Obtaining Information

I do hereby authorize

(agency or personnel)

to release information concerning

to the Speech/Languag Clinic,

(name)

Marywood University, 2300 Adams Avenue, Scranton, Pennsylvania, 18509.

Signature


Date

51

MARYWOOD UNIVERSITY



Authorization for Exchange and Use of Clinical Information

The Speech/Language Clinic is operated in conjunction with the Marywood University Department of Communication

Sciences and Disorders. It is a supervised training experience for undergraduate and graduate student clinicians.

Periodically, video/audio tape samples of individual clients may be made to assist students in the learning process. The

exchange of any or all information obtained in connection with the rendering of clinical services at the Speech-Language

Clinic will be made available confidentially for educational and/or scientific purposes.

Date Client's Name

Signature


52

MARYWOOD UNIVERSITY



ATTENDANCE POLICY

To: Client or Caregiver

From: Renee Jourdanais, Clinic Director

Re: Unexcused Absences

As a reminder, regular attendance is encouraged. If for any reason you are unable to attend a scheduled session;

you are asked to contact the clinic at (570) 348-6299 and cancel your appointment as you would with any other

business or doctor’s appointment. If you do not show up for a scheduled therapy session and no call is received

after a fifteen-minute grace period, you will be given a warning on the first occurrence.

The clinic reserves the right to discharge you from therapeutic services should you or your family member have

an excessive amount of “No Shows” within the semester. If you “No Show” two consecutive sessions, you will

be given a warning of possible discharge should the unexcused absences continue.

______________________________________

Client or Responsible Party

______________________________________

Date

53

Notice Of Privacy Practices As It Relates To

Protected Health Information At The

Marywood University Speech/Language Clinic or Audiology Clinic

(Revised January 2014)

This notice describes how medical information about you may be used and disclosed, and how you can get access to this

information. Please review it carefully.

I. What Is Protected Health Information (PHI) And Disclosure?

Protected Health Information includes health information and other patient information used or disclosed by the

covered entity (i.e. Marywood University Speech/Language Clinic or Audiology Clinic) in any form of oral or

written information. This information includes, but is not limited to client name, address, social security number,

ID #, doctor notes, or any other information that connects information to a specific patient.

The term disclosure relates to any information given to another that relates to a patient’s health. These disclosures

cannot be given unless with authorization by either the patient or the patient’s personal representative. The facility

is responsible to limit the information to only those individuals that need the information for a legitimate purpose.

II. How Does The Marywood University Speech/Language Clinic or Audiology Clinic Use And Disclose Your

Health Information? Marywood University Speech/Language Clinic or Audiology Clinic provides a broad range

of services to both individual clients and the community. If you receive services from the Marywood University

Speech/Language Clinic or Audiology Clinic, your protected health information may be used in the following

ways:

To plan and provide your care and treatment

To educate other health professionals within the clinic

To report to law enforcement when legally obligated

For reports and referrals to other facilities and doctors

For classroom presentations and demonstrations (with names and other identifying information

omitted where possible)

For research purposes with information de-identified

The Marywood University Speech/Language Clinic or Audiology Clinic will not use or disclose your protected

health information except as described in this notice or otherwise authorized by law.

III. Who Will Have Access To Your Protected Health Information?

Department Assistant: PHI is used during daily operations of the clinic when preparing client

charts, notifying students of client cancellations.

Faculty: PHI is used by faculty members within the Department of Communication Sciences and

Disorders when sharing information with students about assessment and therapeutic techniques or

when providing information to classes regarding clinic and professional procedures.

Students: PHI is used by undergraduate and graduate student clinicians within the Department of

Communication Sciences and Disorders as well as in the Marywood University Speech/Language

Clinic when planning and providing services to clients, observing videotapes or listening to

audiotapes to better understand therapeutic techniques, or when observing live therapeutic sessions

54

in the clinic. Students are supervised by ASHA certified and Pennsylvania State licensed speech-

language pathologists and audiologists.

Supervisors: PHI is used by supervisors to consult with and educate students as well as to provide

adequate care to clients under their supervision.

Law Enforcement: PHI is used to inform law enforcement officials/agencies in the case of

suspected child/elder abuse, in response to a court order, or when there is eminent danger to the

client or others.

IV. What Are Your Health Information Rights?

You have the right to do the following with your protected health information:

File a complaint if you believe your privacy rights have been violated

Inspect, correct, and request a copy of your PHI – fees may be incurred for copying/mailing

expenses of requested copies

Obtain an accounting of disclosures

Request a restriction on certain uses and disclosures of PHI

Request communications of PHI by alternative means or at an alternative address

Revoke your consent to use or disclose information to the extent that it has not already been relied

upon

V. How Will You Be Informed Of Changes To This Notice?

If a privacy practice is changed, a revised version of this notice will be provided to all present participants and

beneficiaries for whom PHI is maintained. The revised notice will be provided by either first class mail to an

individual’s present address or hand delivered during the individual’s next appointment at the Marywood

University Speech/Language Clinic or Audiology Clinic. Any revised version of this notice will be distributed to

individuals within 60 days of the effective changes.

VI. How Can You Request Additional Information Or Report A Problem?

If you have questions, would like additional information, or believe your privacy rights have been violated, you

may file a complaint with Renee Jourdanais, MS, CCC-SLP (Clinic Director), or Dr. Patricia Dunleavy

(University Privacy Officer). You may also file a written complaint with the Secretary of the U.S. Department of

Health and Human Services at 200 Independence Avenue SW, Washington, D.C., 20201 or call 1-877-696-6775.

55

Consent To The Use And Disclosure Of Personal Health Information For Diagnosis, Treatment, Clinic Operations,

And As A Teaching Tool

I, , understand and agree that the Marywood University Speech/Language Clinic or

Audiology Clinic may use and disclose protected health information including, but not limited to name, address, health

history, symptoms, evaluation results, diagnosis and treatment information for the purpose of treatment, clinical operations,

as well as a tool for teaching/research. I understand that my information will not be used for any financial gain. I

understand that I must consent to this use and disclosure in order to enroll in or receive services through the Marywood

University Speech/Language Clinic or Audiology Clinic.

I understand and have been provided with a copy of the document entitled, Notice of Privacy Practices As It Relates To

Protected Health Information At The Marywood University Speech/Language Clinic or Audiology Clinic, which provides a

complete description of the potential uses and disclosures of my protected health information. I understand that I have the

right to review the Notice Of Privacy Practices As It Relates To Protected Health Information At The Marywood University

Speech/Language Clinic or Audiology Clinic prior to signing this consent form.

I understand that the Marywood University Speech/Language Clinic or Audiology Clinic reserves the right to change its

privacy practices and will mail a copy of any revised notices to the address that I have provided.

I understand that I have the right to request that the Marywood University Speech/Language Clinic or Audiology Clinic

restrict how my protected health information is used or disclosed for the purpose of planning evaluations, carrying out

treatment, clinic operations, and as a tool for teaching/research. I further understand that the Clinic is not required to grant

any request to restrict the use or disclosure of my information. If, however, the Clinic agrees to a requested restriction, the

restriction is binding on the Clinic.

I agree that I have the right to revoke this consent form in writing, except to the extent that the Clinic has relied upon it.

This consent is binding for the duration of the services provided at the Marywood University Speech/Language Clinic or

Audiology Clinic unless policy or procedure changes are necessary or if upon request of the client, whereby written

notification should be provided.

Client or Personal Representative Signature Date

56

Request for Communication and/or Disclosure Restrictions

I request the following alternatives or limitations relating to communications directed to me by the Marywood University

Speech/Language Clinic:


Accepted/Denied Date

Reason

Signature of Clinic Representative

I request the following restrictions to the use or disclosure of my personally identifiable health information:


Accepted/Denied Date

Reason

Signature of Clinic Representative

57

MARYWOOD UNIVERSITY

DEPARTMENT OF COMMUNIATION SCIENCES AND DISORDERS


Client Assignment

The following client will be assigned to you for this semester of clinical practicum.

Review the client’s file and complete the Initial File Review prior to meeting with your

supervisor for your initial conference.

Client: Clinical Supervisor:

Parents:

Scheduled Time

M T W Th F @ a.m. / p.m.

Start Date:__________________________________

Evaluation Scheduled: Yes No Date: _________________________

Comments:

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MARYWOOD UNIVERSITY


AUDIOLOGY CLINIC

Audiology Assignment

Student Clinician: Audiology Supervisor:

Placement Site:

Scheduled Times:

M T W Th F From To

M T W Th F From To

Scheduled Dates: __________________________ ____________________________

__________________________ ____________________________

__________________________ ____________________________

__________________________ ____________________________

Comments:

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MARYWOOD UNIVERSITY



INFORMATION SHEET

CLIENT: ____________________________________

CLINICIAN: _________________________________

DAYS OF THERAPY: M T W R F

TIME: 9:00 10:00 11:00

1:00 2:00 3:00 4:00

CONTACT INFORMATION: 348-6299

CANCELLATION LINE: Ext. 0

SUPERVISOR: RENEE JOURDANAIS, M.S., CCC-SLP Ext. 2608

MARY MARGARET MAZZACCARO, M.S., CCC-SLP Ext. 2499

ANDREA NOVAK, M.A., CCC-SLP Ext. 2144

BRUCE WISENBURN, Ph.D., CCC-SLP Ext.2226

MARLA KOVATCH, M.A., CCC-SLP Ext. 2259

AMANDA BENNETT, M.S., CCC-SLP Ext. 4508

Clinical supervisors are available to meet with clients, parents, and families throughout the day. We can also be reached by

telephone during the hours of 9:00 a.m. until 5:00 p.m., with any questions or concerns that may arise during the semester.

We encourage client and family participation throughout the therapeutic process and will gladly arrange observation of

individual therapy sessions, if requested. We also request, that if you need to cancel your scheduled appointments, you

kindly call the clinic at 348-6299, in accordance with the absence policy of the Marywood University Speech/Language

Clinic

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MARYWOOD UNIVERSITY



Initial File Review

Semester: Year:

Client: Student Clinician:

Diagnosis: Clinical Supervisor:

Parents: Phone:

Address:

Therapy Schedule a.m./p.m. M T W Th F

The purpose of the following brief report is to provide an outline by which you can develop a clear understanding of your

client, his/her communication problems, and to direct your focus in developing a semester plan. Use the following

information when discussing your client with your clinical supervisor.

Pertinent Information (Medical history, developmental/educational history, current communication abilities)

Previous Semester Progress (Include tests administered and achievement toward STG and LTG)

Previous Semester Recommendations (Include recommended objectives, goals, and suggestions for further testing.)

Plan of Action (Include the behavioral objectives you plan on starting with for the semester.)

61

WEEKLY TREATMENT PLAN

This form is to be completed on a weekly basis, submitted to your supervisor prior to your weekly meeting, and approved

before your next treatment session.

Long Term Goal (LTG): The LTG identifies the anticipated communication behavior one year from treatment for any

disorder (e.g., language, articulation, voice, fluency.)

Short Term Goal (STG): The STG identifies the anticipated communication behavior by the end of the semester for any

disorder (e.g., language, articulation, voice, fluency.)

Behavioral Objective (BO): Identifies the hierarchy of treatment which includes types/levels of cues and prompts (i.e.,

the steps to achieve the STG.)

A. Four (4) Components

1. Rationale: reason for targeting a behavior (e.g., To increase speech intelligibility)

2. Outcome: targeted behavior (e.g., Client will produce the / t / phoneme in IMF positions of single

words)

3. Conditions: the cues and prompts used to assist/facilitate targeted behavior (e.g.,

Spontaneously; model; cue)

4. Criteria: measurement of success (e.g., 9 out of 10 times; 90% accuracy; over 2 consecutive

sessions)

Treatment Methodology: Describes the client/clinician interaction.

A. Discriminative Stimulus: Antecedent

1. The linguistic and non-linguistic contexts used to explain what is expected of your client (e.g., The

clinician will produce /t/ in the initial position of words, introduce a delay, and have the client

repeat the word).

2. The purpose of antecedents is to discuss the target skill, not the therapy activity.

B. Examples of Expected Target Skill

1. List the client’s expected linguistic and/or non-linguistic skill/action would be in response to the

antecedent (e.g., The client will produce /t/ in the initial position of words when given a direct

model).

C. Consequential Strategy

1. Include type and schedule of reinforcement if a desired response was elicited.

2. Include types of cues/prompts to elicit target skills if a desired response was not elicited.

Materials/Activities: Describe/list items you will be using in the therapy session.

R+ Type Schedule: Describe the type and amount of reinforcement given to the client.

Comments: Describe any information that would be important to know for that particular treatment plan (e.g., bombardment

activities, goals to be addressed at a later period of time, testing to take place, monitoring of goal at home, etc.)

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MARYWOOD UNIVERSITY


Weekly Treatment Plan

Client Initials: Diagnosis:

Student Clinician: Treatment Dates:

Supervisor: Week of Treatment:

LTG:

STG:

Behavioral Treatment Methodology Materials R+Type Comments

Objective Activities Schedule

Discriminative Stimulus:

(Antecedent)

Examples of

Expected Target

Skill:

Consequential Strategy:

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MARYWOOD UNIVERSITY


PLAY GROUP LESSON PLAN

Client Initials: Lesson # Student Clinicians:

Group: Concept/ Theme: Supervisor:

Date:

Activity Method Materials R+ type

1.

2.

3.

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MARYWOOD UNIVERSITY


PRAGMATIC GROUP LESSON PLAN

Client Initials: Lesson # Student Clinicians:

Group: Concept/ Theme: Supervisor:

Date:

Activity Method Materials R+ type

1.

2.

3.

65

DATA COLLECTION FORMS

During each therapy session, student clinicians are required to collect data for behavioral objectives. A sample of a data

collection form is provided. Student clinicians and supervisors will select a data collection form based on which format is most

appropriate for the communication skill being targeted.

Each data sheet should include initials of the client, date of the session, and goals addressed. After completing a therapeutic

session, student clinicians will calculate a percent of accuracy and transfer this information to a Daily Outcome Data Log.

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MARYWOOD UNIVERSITY



Data Collection Sheet

Client Initials:____________________________ Date:______________________

1 2 3 4 5 6 7 8 9 10 Accuracy

Goal:

Model/Cue:

Comments:

1 2 3 4 5 6 7 8 9 10 Accuracy

Goal:

Model/Cue:

Comments:

1 2 3 4 5 6 7 8 9 10 Accuracy

Goal:

Model/Cue:

Comments:

1 2 3 4 5 6 7 8 9 10 Accuracy

Goal:

Model/Cue:

Comments:

67

DAILY OUTCOME DATA LOG

The Daily Outcome Data Log is used to document daily therapy sessions and session cancellations. Entries are to be made

immediately following each therapy session. They should be submitted to your Clinical Supervisor with your Weekly Treatment

Plan. The Clinical Supervisor will initial it following review and return it to the Student Clinician to be put in the client’s file.

Each Daily Outcome Data Log should include the name of client, date of the session, goal(s) addressed, and percent of accuracy

achieved for each goal, as well as any behavioral observations/comments regarding the session.

1. Goal

State the behavioral objective, making sure that you include any cues/models if used during therapy, as

well as desired percentage of accuracy.

2. Outcome Data

Record data collected for each behavioral objective implemented during each therapy session. Make sure

the date is recorded under day 1, day 2.

3. Increase From Last Month

For new goals (either the beginning of the semester or when a goal moved to a different behavioral

objective), you would record this column as N/A. For any goal that is currently being worked on and has

been carried over from the month prior, you would record the increase from the last weekly average of

the previous month to the last weekly average of the current month.

4. Increase From Baseline

For goals (either the beginning of the semester or when a goal moved to a different behavioral objective),

you would record the increase from the first day’s data (baseline) to the last weekly average.

5. Behavioral Observation/Comments

Record observations of behavior, circumstances, etc., which impacted the therapy session (e.g.,

inattentive, crying, unable to sit quietly). You will also want to comment on whether or not a goal was

met, if you are moving to a new behavioral objective next session, why a goal was not worked on within

a session, or why the goal has been discharged.

6. Appropriate Codes

N/A: Not Applicable DNT: Did Not Test ↑: Increase

MA: Maintained Accuracy BL: Baseline *: (Issue needing explanation)

CE: Clinician Error V: Variability

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MARYWOOD UNIVERSITY


Daily Outcome Data Log

Client Initials:

Semester/Year:________________________

Goal day 1

/

day 2

/

Wk.1

avg.

day 1

/

day 2

/

Wk.2

avg.

day 1

/

day 2

/

Wk.3

avg.

day 1

/

day 2

/

Wk.4

avg.

day 1

/

day 2

/

Wk.5

Avg.

last

mont

h

from

B.L.

Date: Behavioral Observation/Comments

Date: Behavioral Observation/Comments:

Date: Behavioral Observation/Comments:

69

SESSION EVALUATION FORM

The Session Evaluation Form was developed to provide the student clinician with an opportunity to self-evaluate

his/her clinical performance. The student is required to identify his/her clinical strengths and areas for

improvement as well as comment on the nature of the therapy session. Students should reflect independently

and not solely comment on things that the supervisor had mentioned on the clinical observation form. The

form must be submitted along with the Daily Outcome Data Log and Weekly Treatment Plan to your supervisor

on a weekly basis. This information is to then be discussed with your supervisor during the weekly meeting. The

supervisor should initial it and the student should file it in the Student’s Work Folder.

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MARYWOOD UNIVERSITY



Session Evaluations

Discuss whether objectives were met and if not what occurred. What, if anything, might you have done

differently to improve the process and outcome? How will the interactions change your plan for next session?

Discuss other significant interactions, occurrences and problems. Discuss what strengths and weaknesses you

noticed in your own behavior and intervention (self-evaluate). List any carryover activities assigned to the client.

Date:

Date:

71

SOAP NOTES

SOAP is an acronym for subjective, objective, assessment/analysis, and plan.

The SOAP note form was developed to document therapy progress during a specified treatment period (e.g.,

monthly, every six weeks, every 45 days). Clinic SOAP notes will be written according to specified time lines.

Check the initial semester clinic memo for due dates.

The following information should be included in a SOAP note:

Marywood University


Speech/Language Clinic

SOAP Note

Name: XXXXXXXX Date: (last date seen or scheduled to be seen in the

month)

Student Clinician: XXXXXXXXXX, degree. Supervisor: XXXXXXXXXX, degree, CCC-SLP

S: (Subjective observation): Impressions of the client's behavior. These impressions can be the client's, the

clinician's, or the parent's. Indicate the time period covered by the note and the number of sessions the

client was seen. If sessions were missed, comment as to why.

O: (Objective data): Measurable information is reported in this section of the note. Include accuracy of

client performance (including monthly percentage increase) as recorded on the daily outcome data log.

Ranges should not be reported. If applicable, compare the client's performance with that reported in the

previous SOAP note (e.g., 80% accuracy ( of 5)). Data from any additional testing administered for

screening or re-evaluation purposes should be included included.

A: (Assessment/Analysis): The remaining diagnosis should precede the overall progression of goals. Goals

met (including model levels) and increases noted (model levels can be included, but not necessary)

should be listed. Review of information with client or client’s family, and whether they are in agreement

with results and recommendations should also be included in this section. Lastly, a prognostic statement

regarding anticipated improvements should be included.

P: (Plan): State the overall therapy goals for the next treatment period (1 month). Specific behavioral

objectives should be listed for what you feel will be completed within four weeks. Include over two

consecutive sessions if client is seen twice weekly.

_______________________________

Student Clinician, Degree Clinical Supervisor, Degree, Credentials

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Marywood University


Speech/Language Clinic

SOAP Note

Name: XXXXXXXX Date: 07/01/02

Student Clinician: XXXXXXXXXX, degree. Supervisor: XXXXXXXX, degree.,CCC-SLP

S. XXXXX was seen for 8 out of 10 sessions in the months of May and June. XXXXX did not attend sessions

secondary to doctor appointments. XXXXX was an active participant, playful, and cooperative throughout the

majority of the attended sessions.

O. Therapy focused on improving receptive and expressive language skills and speech intelligibility. XXXXX

followed 2-step commands independently with 89 % accuracy (19). He demonstrated simple spatial concepts

(in, on, under, next to) at sentence level independently with 91% accuracy (8; long term goal met). He said

simple spatial concepts (in, on, under, next to) at word level when given a direct model with 100 % accuracy

(baseline data, goal achieved); independently with 73% accuracy (baseline data over 1 session); and at phrase

level when given a faded model with 94 % accuracy (variability 6; goal met). Goal was changed to phrase level

when given a faded model secondary to XXXXX responding primarily at this level. XXXXX named 4 items in a

category independently with 81 % accuracy (28), 94% accuracy when given a semantic cue (baseline data over

1 session), and 100 % accuracy when given a phonemic cue (baseline data over 1 session). XXXXX named

categories (in a field of 4) independently with 90% accuracy (16; goal met only over 1 session). The client

expressed the function of complex items when given a direct model with 95% accuracy (baseline data; goal met

only over 1 session). XXXXX used regular past tense verbs at word level when given a direct model with 100 %

accuracy (6; goal met), and when given a faded model with 94% (baseline data over 1 session). He used the

present progressive form of verbs at word level when given a direct model with 100 %accuracy (baseline data;

goal met) and faded model with 100% accuracy (baseline data; goal met). He produced /s/ blends in the medial

(M) position of words given a direct model with 77 % accuracy (variability 8). The client produced / l / in the

initial ( I ) position of words given a direct model with 72 % accuracy ( 11). XXXXX produced / v / in the I

position of words given a direct model with 93% accuracy (9; goal met) and faded model with 100 % accuracy

(baseline data over 1 session).

A. At this time mild articulation and mild/moderate receptive/expressive language deficits remain. Goals were

met for demonstrating simple spatial concepts at sentence level independently, following 2-step commands

independently, saying simple spatial concepts at word level when given a direct model and at phrase level when

given a faded model, naming categories (in a field of 4) independently over 1 session, using regular past tense

and present progressive verbs at word level given a direct model and present progressive verbs given a faded

model, and for producing /v/ in the I position of words given a direct model. Increases were noted in naming 4

items of a category and for producing / l / in I position of words. Progress and plan of therapy continue to be

discussed with XXXXX’s mom, Mrs. XXXX XXXXX, who verbalizes agreement. Prognosis is good based on

family support and improvement in treatment.

P. It is recommended that XXXXX continue to receive speech and language therapy twice a week to increase

receptive and expressive language skills and speech intelligibility. The following goals are recommended:

1. To improve receptive language skills XXXXX will follow 2-step commands independently with 90%

accuracy over 2 consecutive sessions.

2. To improve expressive language skills XXXXX will say simple spatial concepts (in, on, under, next to) at

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sentence level given a faded model with 90% accuracy over 2 consecutive sessions.

3. To improve expressive language skills XXXXX will name categories (in a field of 5) given a faded model

with 90% accuracy over 2 consecutive sessions.

4. To improve expressive language skills XXXXX will name 5 items in a category given a direct model with

90% accuracy over 2 consecutive sessions.

5. To improve expressive language skills XXXXX will express the function of complex items independently

with 90% accuracy over 2 consecutive sessions.

6. To improve expressive language skills XXXXX will use regular past tense verbs in phrases given a faded

model with 90% accuracy over 2 consecutive sessions.

7. To improve expressive language skills XXXXX will use present progressive form of

verbs in phrases given a faded model with 90% accuracy over 2 consecutive sessions.

8. To increase speech intelligibility XXXXX will produce /s/ blends in medial position of

words independently with 90% accuracy over 2 consecutive sessions.

9. To improve speech intelligibility XXXXX will produce phoneme / l / in initial position

of words independently with 90% accuracy over 2 consecutive sessions.

10. To improve speech intelligibility XXXXX will produce phoneme / v / in initial position

of words in phrases given a faded model with 90% accuracy over 2 consecutive sessions.

______________________________ ____________________________________

XXXXXXXXXXXXXX, degree. XXXXXXXXXXXXX, degree., CCC-SLP

Graduate Clinician Clinical Supervisor

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REPORTS

The Therapy Progress Report is completed during the last week of the clinic semester. The purpose of the

Therapy Progress Report is to document the client’s treatment progress during the course of the semester. The

format for the report has been established. This report can also be titled Discharge or Discontinuation Report

based on individual needs. See sample form that follows. If the client is being discharged from therapeutic

services the title ‘Therapy Progress Report’ should be changed to ‘Discharge Report’. Discharge of the client

should be so noted in the report with reasons listed for the discharge (e.g., goals of therapy were met, client has

reached functional levels, etc.) and a recommendation for the client (e.g., Re-evaluation should there be a change

in the client’s functional communication abilities, home program provided, etc.)

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Therapy Progress Report

Section I: Identifying Information

Name: Date:

Address: Birthdate:

Age:

Phone: Clinician:

Parents/Spouse: Semester:

Diagnosis:

Section II: Background Information

Think of this as your “S” section of a monthly soap note with some additional information. Briefly

review pertinent medical/developmental information where appropriate, previous therapy information,

diagnosis, and briefly stated goals, as well as information that may add to why the client did or did not

reach goals this semester.

Section III: Progress in Therapy

Think of this as your “O” section of a monthly soap note with more details noted since it is for the entire

semester. To keep everyone organized you are to follow the example given below with separate sections

for Articulation, Expressive Language, Receptive Language, or whatever areas you are working on with

your client. A separate long-term and short-term goal followed by your paragraph(s) of progress is (are)

to be included. You may combine articulation goals if they are the same for several phonemes. You are

to include percentages for the current level (independent or with model) that you are working on with

increases noted.

Articulation

Long Term Goal: To improve overall speech intelligibility the client will produce /m,p,b/ in all positions

of words independently in conversation across conversational settings at 90% accuracy.

Short Term Goal: To increase speech intelligibility, Anna will independently produce /m, p, b/ in all

positions of words in phrases at 90% accuracy.

Anna has independently produced /m/ in the initial position of words at 92% accuracy (increase of 20%,

goal met), in the medial position of words at 90% accuracy (increase of 15, goal met), and in the final

position of words at 91% accuracy (increase of 10, goal met). There was also an increase in the

production of /m/ given a delayed model in the initial position of words in phrases at 90% accuracy

(increase of 10, goal met over one session) and in the medial position of words in phrases at 75%

accuracy (increase of 5). /m/ in the final position of words in phrases was mastered with a delayed model

at 92% accuracy (increase of 30) and is 65% accurate (increase 2) independently.

Anna has produced……(continue with next phoneme).

Long Term Goal: Continue with the next Long Term Goal in this area.

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Short Term Goal: Continue with next articulation goal, etc. and then the paragraph of progress

information.

Expressive Language

Long Term Goal: Same as above.

Short Term Goal: Same as above with your short-term goal listed followed by your paragraph of

progress.

Continue with all other areas addressed followed by long-term and short-term goals and paragraphs of

progress.

Section IV: Diagnostic Results

Results of testing should be reported in this section if your client has been re-evaluated or screened

within that semester. You should list the test (underlined) and a brief summation of the results, which

would include the diagnosis, any recommendations, and improvements or regression from the last time

the test was administered. If you were completing any screenings, assessments, or post testing

throughout the semester, this would also be included in this section. Format of this section can be

variable, however, must be approved by the clinical supervisor.

Section V: Current Status

Think of this as your “A” section of your monthly soap note with more detail since you have the entire

semester to address. Make sure you include areas where progress was made or goals were met, a current

diagnosis, prognosis, and that the results of the semester were reviewed with parent, etc.

Section VI: Recommendations

Think of this as your “P” section of the monthly soap note. This section should include

recommendations for next semester…therapy or no?? It should also include your overall therapy goals

(i.e., to increase receptive/expressive language skills, etc.) as well as suggested short-term goals for the

clinician for the next semester. If this is a discharge from therapy, be sure to include reasons for

discharge and recommendations for the client.

Section VII: Signatures

Make sure you have a space for your signature as well as for your supervisor. Example is shown below.

Be sure to include degree and credentials where appropriate.

________________________ ___________________________

XXXXXXXXXX, degree. XXXXXXXX, degree., CCC-SLP

(Under)Graduate Student Clinician Clinical Supervisor

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STUDENT PERFORMANCE EVALUATIONS

Clinical supervisors provide qualitative assessments of the student clinician’s performance according to standards set forth

by ASHA. Clinical skills, written documentation/report writing, and professionalism are evaluated by the supervisor

when assessing a student clinician’s performance. Supervisor/Supervisee meetings are held weekly and written feedback is

provided following each supervised observation.

Quantitative evaluations are also completed by the supervisor twice during the semester for speech-language practicum and

once at the end of an audiology practicum. The student clinician’s strengths, weaknesses, and areas for continued growth

and development relative to clinical competencies are assessed. At the end of the semester, a final grade will be determined

based on the quantitative and qualitative feedback. If a student clinician has more than one supervisor, the final grade will

be an average of all grades for that semester.

Copies of the Clinic Observation Forms, Clinical Practicum Evaluation Forms, and Audiology/Aural Rehabilitation

Practicum Evaluation Form follow. The original form will be retained by the Clinical Supervisor, while the student

clinician retains the carbon copy. At the end of the semester the original form will be filed in the student’s permanent

folder, which is maintained by the Clinic Director.

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STUDENT EVALUATION OF CLINICAL SUPERVISION

At the end of each semester students will be provided with the opportunity to evaluate their clinical and/or diagnostic

supervisors.

A copy of the student Evaluation of Clinical Supervision Form follows. Student feedback is valued and will be reviewed

by the CSD Department Chair, Director of the Master’s Program in Speech-Language Pathology, and the Clinic Director.

Feedback will also be shared with clinical supervisors so that any comments or concerns may be addressed.

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DOCUMENTATION OF CLINICAL CLOCK HOURS

Student clinicians are responsible for logging clinical hours on a daily basis onto the Clinical Hour Tracking Forms

(Pediatric, School Age, Adult, and Geriatric), copies of which follow, as well as the Typhon Hour Tracking System. At the

end of each semester the student clinician is responsible for having his/her clinical supervisor verify accrued clinical clock

hours. After transferring the appropriate number of hours onto the Clock Hour Summary Form, the clinical supervisor will

then attach the individual tracking forms and sign the summary form. If there were supervisors that completed coverage

supervision, the hours need to be logged under their name on Typhon and you will need to have them sign off on these

hours at the end of the semester as well. This form must be given to the Clinic Director, who will then verify the hours in

the Typhon System. All paper information will then be kept in the student’s permanent file.

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Marywood University


Clock Hour Tracking Form

Preschool (Birth – 5 years)

Date

Articulation Fluency Voice & Resonance Receptive & Expressive

Language

Swallowing

Dx Tx Dx Tx Dx Tx Dx Tx Dx Tx

Total

Minutes

Total

Hours

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Date

Cognitive

Communication

Social

Communication


Communication

Hearing Staffing &

Counseling


Total

Minutes

Total

Hours

102

Marywood University



School Age (6 – 18 years)

Date


Language

Swallowing


Total

Minutes

Total

Hours

103

Date

Cognitive

Communication

Social

Communication


Communication

Hearing Staffing &

Counseling


Total

Minutes

Total

Hours

104

Marywood University



Adult (19 – 69 years)

Date


Language

Swallowing


Total

Minutes

Total

Hours

105

Date

Cognitive

Communication

Social

Communication


Communication

Hearing Staffing &

Counseling


Total

Minutes

Total

Hours

106

Marywood University



Geriatric ( ≥ 70 years)

Date


Language

Swallowing


Total

Minutes

Total

Hours

107

Date

Cognitive

Communication

Social

Communication


Communication

Hearing Staffing &

Counseling


Total

Minutes

Total

Hours

108

Marywood University


Clock Hour Summary Form

Student Clinician Semester

Preschool (Birth – 5 years) Adult (19 – 69 years)

Dx Tx Dx Tx

Minutes Hours Minutes Hours Minutes Hours Minutes Hours

Articulation Articulation

Fluency Fluency

Voice &

Resonance

Voice &

Resonance

Receptive &

Expressive

Language

Receptive &

Expressive

Language


Cognitive

Communication

Cognitive

Communication

Social

Communication

Social

Communication


Communication


Communication

Hearing Hearing

Staffing &

Counseling

Staffing &

Counseling

School Age (6 – 18 years) Geriatric ( ≥70 years)

Dx Tx Dx Tx

Minutes Hours Minutes Hours Minutes Hours Minutes Hours

Articulation Articulation

Fluency Fluency

Voice &

Resonance

Voice &

Resonance

Receptive &

Expressive

Language

Receptive &

Expressive

Language


Cognitive

Communication

Cognitive

Communication

Social

Communication

Social

Communication


Communication


Communication

Hearing Hearing

Staffing &

Counseling

Staffing &

Counseling

______ Total Minutes

_________ Total Hours

Clinical Supervisor Date

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FAMILY SATISFACTION SURVEY

The Family Satisfaction Survey provides the client/family member an opportunity to evaluate the services that they received

at the Clinic. The client/family is presented with the survey at the end of the clinical semester, asked to anonymously

complete the form, and either place it in the appropriate location outside the main clinic office or to return it by mail. If the

survey was not handed to the client/family, it is the student clinician’s responsibility to mail the survey to the client/family

with a return, stamped envelope for their convenience. If this occurs, it should be documented on the Communication Log

Sheet.

The survey results are reviewed and compiled by the Clinic Director. The information is shared with all CSD faculty.

Areas which need improvement are identified and discussed. Modifications to the clinical education program are

implemented as deemed appropriate.

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AUDIOLOGY CLINIC

Family Satisfaction Survey – Audiology Services

(Revised 7/1/08)

Read each item carefully and circle the one answer that is best for you. Please be sure to mark NA (Not Applicable) if an

item does not pertain to you. We ask that you provide an explanation in the comment section for a score of 2 or below so

that we can address any concerns and make appropriate changes. Any additional comments are also welcome.

Strongly Agree - 4 Agree - 3 Disagree - 2 Strongly Disagree - 1 NA – 0

PROFESSIONAL STAFF

1. The audiologist was courteous, pleasant, and professional. 4 3 2 1 0

2. The audiologist created a comfortable atmosphere for sharing

information.

4 3 2 1 0

3. The audiologist was knowledgeable. 4 3 2 1 0

4. The student clinician (if present) was courteous, pleasant, and

professional.

4 3 2 1 0

5. The student clinician (if present) created a comfortable atmosphere

for sharing information.

4 3 2 1 0

6. The student clinician (if present) was knowledgeable. 4 3 2 1 0

PROFESSIONAL SERVICES

1. The appointments were scheduled at a convenient time for my family

and/or me.

4 3 2 1 0

2. The audiologist and/or student clinician clearly reviewed the results

of the treatment sessions.

4 3 2 1 0

3. Opportunities were offered to me, my spouse, and/or other family

members to participate and/or interact during appointment.

4 3 2 1 0

4. Opportunities were offered to me, my spouse, and/or other family

members to contact the audiologist to discuss any further concerns,

ask additional questions and/or, schedule follow up visits.

4 3 2 1 0

5. The audiologist made me aware of payment information and

insurance coverage.

4 3 2 1 0

6. The audiology services provided were adequate and benefited my

family member and/or me.

4 3 2 1 0

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7. I would recommend the Marywood University Speech Audiology

Clinic to other individuals.

4 3 3 1 0

ASSESSMENT PROCESS (Please complete only if an Audiologic Evaluation (Hearing or CAPD Test) was

completed.)

1. The evaluation was scheduled and conducted in a timely manner. 4 3 2 1 0

2. To prepare for the evaluation process, the audiologist and /or student

clinician discussed the purpose of the evaluation.

4 3 2 1 0

3. Sufficient time was allowed for me and/or family members to ask

questions and provide information.

4 3 2 1 0

4. The audiologist's responses to my questions were clear and helped

me and/or members of my family understand the nature of the

hearing and/or audiology processing deficit and the recommended

course of treatment.

4 3 2 1 0

5. If used, professional terminology throughout the evaluation and

subsequent report was clearly explained.

4 3 2 1 0

6. The audiologist and/or student clinician encouraged me and/or other

family members to participate in the decision-making process about

recommendations.

4 3 2 1 0

7. Evaluation results were discussed in detail and additional referrals to

other professionals were made if necessary.

4 3 2 1 0

8. In my opinion, the Audiologic/CAPD evaluation was conducted in a

family-centered manner.

4 3 2 1 0

COMMENTS (Your comments are appreciated and will help us to enhance our clinical services. Please feel free to

use the reverse side of this survey for additional space.)

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CSD ADMINISTRATIVE POLICIES AND PROCEDURES

Following are several important policies, which reflect the overall operation of the CSD Department.

1. Confidentiality

Health care professionals have a legal and ethical responsibility to maintain client confidentiality. Student clinicians must

not disclose information about a client/family acquired in the context of a therapeutic relationship. Information regarding

privacy issues and confidentiality will be addressed throughout your career at Marywood University as well as in clinic

meetings and Undergraduate/Graduate Clinic Methods Courses.

Client files contain confidential information and are kept in a file cabinet in the secured computer area of the Student

Preparation Room (McGowan 1052). Students must sign-out/sign-in a client file on the Client Folder Sign Out Sheet

(sample follows), located in the Clinic Log Book found in McGowan 1052. Under no circumstances are the files to be

removed from the Clinic area with the exception of weekly meetings. Only CSD faculty and student clinicians enrolled in

clinical/diagnostic practicum courses may have access to client files.

Student clinicians are also reminded to follow confidentiality policies in relation to use of copy machines and computer

printers. Under no circumstance should client information be copied via the use of a copy machine. Printouts of client

specific information within our locked computer area should continue to be carefully monitored as other individuals may

have access to printers.

Finally, student clinicians should follow confidentiality and privacy policies when speaking to a client/family either directly

or via the telephone. Client specific information should not be shared in a public area where other individuals may be

within listening distance. Information should be shared in a private area when available or in the most discrete location if

complete privacy is not possible. Failure to comply with any of the above mentioned confidentiality issues will result in

actions, as in accordance with the CSD conduct policy.

2. Code of Ethics

Student clinicians will be receiving information on the ASHA Code of Ethics throughout their academic coursework and

clinical practicum experiences. This information will also be discussed in CSD 361, 518P, 506P, 517P. All students are

expected to abide by the ASHA Code of Ethics.

3. Clinician/Client Relationship

In order to establish and maintain appropriate, professional relationships with clients and their families, student clinicians

are asked to refrain from any personal involvement with the client/family that would compromise the integrity of the

clinical process. Examples of inappropriate behavior would be accepting social invitations, engaging in intimate

conversations, and/or providing clients/family members with your home telephone number or address. The Clinical

Supervisor is available to discuss the appropriateness of social exchanges.

4. Speech-Language-Hearing Screening Policy (Effective Fall 2013)

Policy Statement: All incoming graduate students will participate in a mandatory speech/language and hearing screening

during their first semester enrolled in the CSD program for the purpose of identifying and remediating any communication

deficits that may interfere with interactions with clients, families, supervisors, etc. Undergraduate students, unless

previously identified by CSD faculty/staff member as having a suspect communication deficit, will be screened during the

spring semester of their freshman year. Any transfer student entering after his/her freshman year will be screened in the

semester that he/she enters the program. It is mandatory that all students be screened prior to starting clinical practicum.

The Clinic Director will determine the screening schedule and inform students of the day/time that screenings will occur.

Failure to comply with this policy and the following procedures will delay the student’s enrollment in Clinical Practicum.

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Procedure:

1. All students will receive a Pass/Fail rating for both speech/language and hearing. Documentation of the screening results

will be kept in the student’s clinical file, which is maintained by the Clinic Director.

2. For those students who fail the speech-language screening, a formal speech-language evaluation will be scheduled. It

will be the student’s responsibility to contact the Clinic Director for an appointment within one week of the screening.

3. For those students who fail the hearing screening, a formal audiological evaluation will be scheduled. It will be the

student’s responsibility to contact our Clinical Audiologist for an appointment within one week of the screening.

4. Following the evaluation, it is expected that the student will follow through with all recommendations for treatment

and/or referral for further testing. Documentation of the same will be required and kept in the student’s clinical file.

5. For those students in which phonological features observed during the screening are different from Standard American

English (SAE) dialect, then:

a. An interview with the student would be warranted to find out if the student self-identifies as a speaker with a dialect

different from SAE.

b. If the student does not self-identify with a dialect different from SAE, then the student would fail the speech-language

screening, and step #2 would be followed.

c. If the student does self-identify with a dialect different from SAE, then the features of the student’s speech would be

reviewed to see if these features are documented as typical characteristics of the specified dialect. Dialects may differ by

features other than phonology (such as syntax or semantics), but it is assumed that students with dialectal differences would

be able to model non-phonological SAE features.

d. A determination would be made as to whether or not the characteristics would be a substantial impediment to effective

communication with SAE speakers. If a student shows significant comprehension or expressive communication deficits in

SAE that go beyond a dialectal difference, such as features common in ESL or hard-of-hearing individuals, then a full

evaluation with possible therapy may be warranted. In most cases, dialectal differences would not affect functional/clinical

communication in SAE and would not need further assessment.

e. A student who cannot produce a feature of SAE and is assigned a client who speaks SAE with difficulty producing that

specific SAE feature, then the student clinician may use other strategies to produce a model, such as providing a recording

of an SAE speaker producing the target feature.

Dialectal Difference Statement

It is the position of the American Speech-Language Hearing Association that “no dialectal variety of English is a disorder

or a pathological form of speech or language. Each social dialect is adequate as a functional and effective variety of

English.” (http://www.asha.org/policy/PS1983-00115.htm).

A dialectal difference, whether ethnic or regional, is a common form of communication between members of a community.

A communication disorder is “impairment in the ability to receive, send, process, and comprehend concepts or verbal,

nonverbal and graphic symbol systems” (ASHA, 1993, p. 40). Common communication characteristics that are due to a

disability, such as hypernasal speech for individuals with a severe hearing loss, would not be considered a dialectal

difference but a disorder.

A 1998 position statement by ASHA states that students with accents and/or dialects may provide clinical services as long

as they demonstrate adequate knowledge of communication and communication disorders, diagnostic and clinical case

management skills, and the ability to model target speech and language productions (ASHA, 1998). A 2011 ASHA

Professional Issues Statement revised the requirement for modeling, stating “the reference in the document to ‘modeling’

may be dated. Technological advances and applications for clinical service delivery today are such that modeling can be

http://www.asha.org/policy/PS1983-00115.htm

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provided through a variety of means in the clinical setting. The use of computer applications, software, recordings, and the

like give clinicians multiple options for providing models or presenting auditory stimuli, so their accent may be less of an

issue for providing an appropriate model in some cases. The dynamics of clinical service delivery, though, have also

changed, and clinician engagement with clients is generally much more extensive than a clinician simply providing a model

and a client attempting to repeat it. In addition, speaking with an accent is often related to hearing with an accent (Flege,

1995); thus, it is likely that a clinician's ability to model particular speech sounds may well be influenced by his or her

ability to perceive the client's speech accuracy and to internalize features of target productions.” (www.asha.org/PI2011-

00324.htm)

The faculty in the Marywood University Department of Communication Sciences and Disorders has defined a

communication difference and communication disorder as follows:

Difference: a speech/language difference is defined as a different dialect, native language, or second language that results

in a different pronunciation, production, or construction of speech/language or the intended message in which the meaning

conveyed is fully understood by the communication partner.

Disorder: a speech/language disorder is defined as difficulty producing sounds, differences in voice quality, interrupted

fluency of speech, and/or difficulty receiving, understanding, or formulating ideas and information both in written and oral

language.

The field of communication sciences and disorders requires that students have a high standard of proficiency with both

written and spoken English. However, with growing linguistic minority populations, the Marywood CSD Department will

have students who speak with an accent or a dialect difference from what is common in the Northeast Pennsylvania and

surrounding regions (e.g., New York, New Jersey). If students show adequate knowledge of normal and disordered

communication, diagnostic skills, and clinical case management, the communicative difference alone should not hinder

their success in clinical work, even if they demonstrate difficulty directly modeling certain linguistic features due to their

accent or dialectal difference. In those cases, use of indirect modeling may be possible, such as the use of recordings of

speakers with the same dialect as the client. Student clinicians should recognize when their difficulty directly modeling a

linguistic feature is hindering the progress of the client, and make suitable adjustments as needed. However, written

language in reports is typically more formal, and should reflect the accepted Standard American English rules of syntax,

spelling, and semantics.

The Marywood University Department of Communication Sciences and Disorders requires screenings of all undergraduate

students in the department. If, in this screening, phonological features are seen that are different than SAE, then it will be

determined whether these features represent a dialectal difference or a communication disorder.

References:

American Speech-Language-Hearing Association. (1983, September). Social dialects. Committee on the Status of Racial

Minorities. Asha, 25, 23-27.

American Speech-Language-Hearing Association. (1993, March). Definitions of communication disorders and variations.

Ad Hoc Committee on Service Delivery in the Schools. ASHA, 35 (Suppl. 10), 40–41.

American Speech-Language-Hearing Association. (1998a). Students and professionals who speak English with accents and

nonstandard dialects: Issues and recommendations [Position statement]. Available from www.asha.org/policy.

Flege, J. E. (1995). Second-language speech learning: Theory, findings, and problems. In W. Strange (Ed.), Speech

perception and linguistic experience: Issues in cross-language research (pp. 229–273). Timonium, MD: York Press.

American Speech-Language-Hearing Association. (2011). The clinical education of students with accents [Professional

Issues Statement]. Available from www.asha.org/policy.

Students with Documented Hearing Loss Policy-

Students who have documented hearing loss will be exempt from the CSD department’s traditional hearing screening

requirement. However, these students will be required to complete the CSD department’s traditional speech and language

screening. Students with documented hearing loss must provide the Clinic Director with documentation, such as

audiogram(s)/diagnostic report(s) indicating the presence of hearing loss. For these students, a modified hearing screening

http://www.asha.org/policy/PI2011-00324.htm#r22

http://www.asha.org/policy/PI2011-00324.htm#r22

http://www.asha.org/policy

http://www.asha.org/policy

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will be performed in the sound treated booth using the Quick Speech In Noise Test. Sentences in background noise will be

presented in the free field at decibel levels considered to be near normal conversational speech intensity (65/70dBHL or

comfortable/slightly loud listening level, depending on the Pure Tone Average). If students utilize amplification, testing

will be completed in the unaided and aided conditions. The individual student’s test results will be compared to QuickSIN

criteria and recommendations will be made depending on the category into which the student’s scores fall. This may result

in a recommendation of amplification of any type in order to continue in the CSD program.

5. Dress Code

Student clinicians are meeting the public in a professional capacity and are to dress accordingly. As deemed appropriate by

the faculty and staff of the department, women should wear skirts and dresses of an appropriate length or pants. It is

inappropriate to wear tank tops, low-cut tops, leggings, shorts, jeans, or sneakers. Men should wear a professional

casual/dress shirt with pants. In the summertime, sandals are allowed, however, they must be worn with stockings or socks

at all times when you have direct client contact. Lip and tongue piercings should be removed as they may interfere with

intelligible speech, a skill that is expected of all student clinicians. Nose rings should also be removed. Visible tattoos

should be covered when working in direct contact with clients/families. In addition, hair coloring/dying with color outside

the typical (brunette, black, blonde, red, gray) is discouraged and also deemed unprofessional. These types of accessories or

physical changes, although used to show individuality and diversity, are not considered to be acceptable when working with

clients at the Marywood University Speech/Language or Audiology Clinics (including associated groups) as well as when

you are participating in off-campus assignments (internships, EI screenings, etc.). Students need to be neat and clean in

appearance and demonstrate proper hygiene when working with clients in any capacity. If a CSD faculty or clinical staff

member deems a student’s attire or hygiene to be inappropriate or the student to be lacking in appearance, the student will

be asked to leave his/her assignment for that day. Continued instances of this behavior will result in follow-up per the CSD

Department Professional Conduct Policy.

6. Taping Policy

Taping of a faculty member/clinical supervisor can only be done with that individual's permission, for each time a student

wishes to tape. Tapes can only be used for educational purposes (i.e., note taking, review of class material, studying). It is

illegal to tape any individual without their knowledge and consent. It is also illegal to use a tape for anything other than its

intended purposes. Students are expected to comply with this policy or they can be held responsible.

7. CSD Department Academic and Clinical Conduct and Dispositions Policies

Marywood University Department of Communication Sciences and Disorders

Academic and Clinical Conduct Policy (Revised Spring 2012)

The faculty of the Communication Sciences and Disorders Department requires students to conduct themselves as

professionals. As such, students are expected to act in a manner that displays the highest regard for human dignity.

Students are also expected to demonstrate personal qualities that are required for professional clinicians as found in the

Eligibility Requirements for Essential Functions for Students (Spring 2009) and the Disposition Requirements Policy

(Spring 2012) which may include but are not limited to: effective communication, intellectual, cognitive, sensory and motor

skills, and observational abilities. Professional behavior is expected both in the classroom and other relevant professional

settings (e.g., during all clinical/diagnostic practicums, off-campus clinical internships & externships, conducting research,

and when interacting with peers).

Academic

If a faculty member reports an incident of behavior exhibited by a student that is considered to be a breach of the

Marywood University Academic Honesty/Conduct policy the following consequences may occur (as listed in the

undergraduate and graduate catalogs and student handbook):

Academic Honesty

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A failing grade for the assignment

A failing grade for the entire course

Please refer to individual class syllabi for specific details. Typically, course instructors determine the consequences of the

incident, however, the department chairperson and/or dean may intervene if necessary based on the severity of the

infraction. Two or more established cases of academic dishonesty can result in suspension and/or dismissal from the

university.

Conduct

The conduct policy of the university has been developed to enlighten students as to the consequences of less desirable

actions and to promote responsible behaviors. The process is typically limited to behaviors that negatively affect the

pursuit of educational objectives and support of the University’s core values. No specific policy statement can apply to

every situation; therefore, each case will be handled on an individual basis. In such instances, students will be referred to

the Dean of Students for disciplinary action. Please refer to the student handbook for a complete description of the

University Conduct Policy.

Clinical

If a faculty member reports an incident of behavior exhibited by a student that is considered to be unprofessional (e.g.,

inappropriate verbal and/or non-verbal behavior, non-compliance with established professional expectations, demonstrating

a lack of follow-up/follow through, exhibiting inappropriate conduct, failure to comply with CSD policies & procedures,

etc.) the following will occur:

The first incident will result in a verbal warning initiated by the academic and/or clinical faculty member

identifying the infraction, with written documentation recorded for the verbal warning.

The second incident will result in the student being placed on Professional Probation (i.e. a status associated with a

specific time frame in which skills/actions are monitored for improvement) with written follow-up. If the student

has been identified as lacking in professional qualities, additional guidance and suggestions to rectify the deficit

area will be provided by the academic and/or clinical faculty member(s) to facilitate the student’s overall

professional development, generally in one semester. Following the plan of action, should additional instances

arise or insufficient growth occur, the student will progress to the next level of Professional Probation.

A third incident will result in any or all of the following and supporting documentation will be kept on file:

On-Campus:

Removal from clinical practicum where the student will lose privileges to work with clients in the on-

campus clinic and any off site locations (e.g., Head Start, Health Fairs, etc.). No tuition refund will be

provided.

A failing grade for the clinical practicum will be earned. The student will be responsible financially for

retaking the course as part of the degree requirements. No clinical hours will be accrued should a failing

grade occur.

Graduation may be delayed.

Dismissal from the program may result.

Off-Campus:

The student may be asked to leave the practicum site, and in doing so, lose all tuition fees associated with

the practicum. No tuition refund will be provided.

A failing grade for the clinical practicum will be earned. The student will be responsible financially for

retaking the course as part of the degree requirements. No clinical hours will be accrued should a failing

grade occur.

Re-assignment to an alternate practicum site will occur the following semester, potentially delaying

graduation. Full tuition for that new practicum course and subsequent practicum site(s) will have to be

paid by the student to the university.

Dismissal from the program may result.

Any student found lacking in appropriate academic and/or clinical professional conduct may be placed on probation and

given one semester to rectify the issues outlined in a written corrective action plan or may be dismissed from the CSD

Department. If the CSD Department academic and/or clinical faculty member(s) believes that the corrective action plan has

been completed successfully, the student will be allowed to continue in his/her program. Any student deficient in

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compliance with the requirements may be subject to dismissal from the program regardless of their status. Students will be

given the opportunity to meet with a panel of academic and/or clinical faculty in the CSD Department in order to attempt an

informal resolution of any such concerns. Failure to resolve these concerns informally may lead to a full departmental

review, probationary status, a corrective action plan, and possible dismissal. Students may appeal any CSD Department

faculty decisions following the grievance procedures of the Reap College of Education and Human Development

(RCEHD). Information about appeals procedures for the RCEHD is available from the Dean's Office and can be found in

the current catalog.

Marywood University Department of Communication Sciences and Disorders

Disposition Requirements Policy (Effective Spring 2012)

The field of speech-language pathology requires working in close contact with others, including a wide variety of clients,

families, and team members. Therefore, students must not only show a sufficient knowledge base and the clinical skills to

apply this knowledge, but they must also show adequate interpersonal skills. Students are responsible for demonstrating

adherence to the Disposition Policy when participating in the classroom or MU clinic as well as when representing the

University Department during any off-campus activities including internships/externships, volunteer or in-service learning

opportunities, as well as when attending professional meetings/conferences. The following disposition characteristics are

required for all students.

For all class and clinical work, students must demonstrate:

1. A positive attitude. A positive attitude includes being a source of inspiration not degradation to fellow classmates,

professors, supervisors, and clients. Examples of violations of this disposition are: a) gossiping, b) maintaining a

defensive stance when receiving constructive criticism from professors and supervisors, and c) presenting a flat or

negative affect while seeing a client.

2. Punctuality. Students should arrive for any scheduled activity on-time; this includes classes, research assignments,

supervision meetings, and advising meetings. Examples of violations of this disposition are: a) arriving late to

class, b) arriving late to a supervisory meeting, and c) arriving late to ‘run a participant’ during research activities.

3. Respect. Students are expected to show respectful tolerance of all clients, families, faculty and supervisors. This

would include not interrupting supervisors or professors who are conversing with others; respecting that all ideas,

thoughts, and well-founded conclusions deserve to be heard; and monitoring your own reactions and facial

expressions to ensure you are not sending inappropriate non-verbal messages.

4. Interpersonal skills. While speaking with others, students should monitor non-verbal aspects of communication.

This includes maintaining an appropriate level of loudness, speech intelligibility, language clarity, formality,

personal space, facial expressions/communication, relevancy, and vocabulary appropriate to the situation.

5. Honesty. Students are expected to be honest about their activities at all times. This includes maintaining accurate

client data records, ‘owning’ up to mistakes (regardless of the consequence), and adhering to the University’s

honesty policy. Examples of violations of the disposition include: a) misrepresenting work done by others as your

own, b) ‘skipping out’ on additional clinic duties (e.g. cleaning) but reporting it as done, and c) not reporting

violations of HIPAA code.

6. Problem Solving. Students are expected to seek solutions to problems that address their needs as well as the other

parties involved. Students are expected to collaborate and communicate with others as appropriate. This would

include identifying problematic interpersonal situations before they occur and avoiding them; directly maintaining

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a presence in all ‘group’ work in classrooms; and speaking directly with a faculty, supervisor, staff member or peer

when the student has a concern/grievance. Examples of violations include: a) noticing that more office supplies

are needed in the clinic room but failing to go get them and b) not allowing a group member to view your work

when it has to be submitted as a team.

7. Appropriate professional demeanor: Hygiene, grooming, and appearance. Students should ensure that they are

dressed according to the standards listed in the Marywood clinic handbook. They should ensure that they have

appropriate standards of hygiene. Examples of violations include: a) not using appropriate deodorant or other

personal grooming products, b) wearing ripped or stained clothing when in direct client contact, and c) having

unwashed hair or body odor when in direct client contact.

8. Openness and acceptance of feedback from supervisors and instructors. It is important that students understand

that feedback provided to them during a clinical supervisory meeting or classroom discussion/presentation is

provided for the student’s professional growth. Students should always ask for clarification of expectations and/or

the supervisor’s/instructor’s feedback. Examples of violations include: a) talking over the supervisor/instructor as

he or she tries to provide verbal critiques of the student’s performance and b) constantly providing explanations for

their behavior rather than listening to the supervisor’s/instructor’s critique of performance.

Please refer to the CSD Department Academic and Clinical Conduct Policy for consequences of being in violation of the

disposition policy.

8. Hour Accrual Policy

On Campus Clinical Practicum (CSD 468A, 516A,B,C, 521)

If a student earns a final grade that is less than a B- with an individual client/diagnostic evaluation in any of these clinical

experiences the following consequences will occur:

The student will need to develop a clinical remediation plan with his/her individual supervisor to promote success

in future clinical endeavors and to meet ASHA certification standards.

The student will not be able to count any of the clinical hours accrued for that individual clinical experience

towards the number of hours required for ASHA certification.

If the student earns an average grade of less than a B- for all clients seen in a practicum experience, he/she will

need to repeat the clinical experience, and again, hours will not be counted. It will be the student’s responsibility

to pay tuition and any required fees associated with repeating any clinical practicum experience.

On Campus Clinical Practicum (CSD 470A/B, 522) and Off Campus Practicum (519I, 520E, and EDUC 597)

If a student earns a grade that is less than a B- (or an Unsatisfactory in the case of EDUC 597) for these cumulative clinical

experiences the following consequences will occur:

The student will need to develop a clinical remediation plan with his/her supervisor to promote success in future

clinical endeavors and to meet ASHA certification standards.

The student will not be able to count any of the clinical hours accrued for that clinical experience towards the

number of hours required for ASHA certification.

The student will need to re-register for the practicum experience (time permitting when a new site is available), and

again, hours will not be counted. It will be the student’s responsibility to pay tuition and any required fees

associated with repeating any clinical practicum experience.

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Following are several important policies, which reflect the overall operation of the Marywood Speech/Language

Clinic:

1. Clinic Materials/Diagnostic Tests: Loan Policy

All clinic materials (including tape recorders, microphones, Ipads, and AAC systems) and diagnostic tests may be

borrowed from the Clinic on a temporary basis. To borrow materials, the student clinician must sign-out and sign-in on the

Clinic Materials Sign Out Log Form (sample follows), located in the Clinic Log Book, found in McGowan 1052. Student

clinicians who are completing the diagnostic practicum will have first preference over materials. If materials are to be

checked out overnight, the clinician must sign for the materials after 4:00 p.m. and must return them by 8: 30 a.m.

Materials for therapy may only be checked out 1 hour prior to a treatment session and must be returned immediately

following the session. (Refer to the Diagnostic Practicum Handbook for the specific procedures regarding the loan of

diagnostic tests/assessment materials.)

Lost or broken materials should be reported to the Clinical Supervisor and/or Clinic Director. All therapy/diagnostic

materials must be washed according to current Universal Precautions Procedures, as necessary, before returning such

resources.

2. Client Referrals

Clients may be referred by a variety of sources such as parents, physicians, psychologists, social workers, speech-language

pathologists, audiologists, vocational rehabilitation counselors, and educators.

All incoming requests for service are received by the CSD Department Assistant and forwarded to the Clinic Director

and/or a Clinical Audiologist for initial client contact. A Clinical Referral Form is completed and a case history and release

of information forms are subsequently sent to the client or parent, along with a clinic brochure. This packet must be

completed and returned to the Clinic before an evaluation takes place. Further information from other agencies may be

requested by completing the appropriate release forms, samples of which have been included in this handbook.

3. Client Attendance/Cancellations

The Clinic serves as part of a program that prepares students to enter the field of Speech-Language Pathology and is open

to the community at large. Clinical supervisors and student clinicians should convey to clients the importance of keeping

scheduled appointments (i.e., they provide for consistency in treatment and ongoing supervision of students) and that the

Clinical Supervisor should be called as soon as possible if a cancellation is necessary. Clients/families will be provided

with a copy of the Marywood University Speech/Language Clinic attendance policy and asked to review and sign off on the

information (sample previously provided). Signed forms will then be kept in the client’s chart. Supervisors are responsible

for disseminating information regarding the attendance policy to student clinicians and clients/families. Supervisors, the

Clinic Director or the Department Assistant will relay information regarding a current therapy session cancellation to the

student clinician, who should document it on the Communication Log Sheet in the client’s file.

If the client is late, wait fifteen minutes before assuming that the client is not coming. Inform the Clinical Supervisor and

request permission before leaving the Clinic. Document the absence on the Communication Log and Attendance Sheets. If

a client is absent for a session and has not called to cancel the session, the student clinician should call the client to question

the absence, document the conversation on the Communication Log Sheet, and inform the Clinical Supervisor. Clients

with excessive absences or cancellations should be informed that they may be discharged from the Clinic and their spot will

be offered to a client on our waiting list, should the absences continue. A letter will be sent out to the parent and referring

Doctor regarding the discharge from services, and rationale containing how many days were missed if attendance had not

improved.

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4. Student Clinician Attendance/Cancellations

Dependability is a characteristic expected of all professionals. Student clinicians are expected to conduct all scheduled

treatment sessions. Sessions are expected to begin and end on time.

Cancellations are acceptable only in the following situations:

1. Cases of a medical emergency or severe illness for which the student will be required to provide

appropriate documentation.

2. An accident on the day the therapy session is scheduled.

3. Death of a family member or close friend.

Student clinicians must have the client’s phone number with them if it is a 9 a.m. client. If a student clinician is unable to

attend a therapy session, the Clinical Supervisor must be contacted to request permission to notify the client. The student is

not to call the client independent of the Clinical Supervisor’s permission, unless an early morning appointment is scheduled

(i.e., before or at 10 AM.) In this case, the student clinician may call the client directly to cancel the appointment. The

student clinician should then notify his/her Clinical Supervisor of the cancellation. This should be documented on the

Communication Log in the client’s file. If a student clinician is unsuccessful in contacting the client, he/she must inform

their Clinical Supervisor immediately. If a clinician cancels a session, an offer to the family/client must be made for a

make-up session within two weeks. The times to offer will be given to the clinician by the clinical supervisor based on the

clinician availability sheet submitted to the clinic director at the beginning of the semester. The student alone will not

choose the time of the rescheduled therapy session. If the student does not follow this protocol and offer the rescheduled

times to the family/client, it will result in the lowering of the overall clinic grade for that client by one letter grade.

5. Marywood University Holidays and Inclement Weather

It is the student clinician’s responsibility to notify the client/family about holidays in which the University is closed. The

Clinic observes all such holidays. Refer to the University’s calendar for such information.

The student clinician is also responsible to inform the client/family of the following information should inclement weather

occur on their scheduled therapy day.

Marywood University Snow Line

961-4SNO

If the university is closed, your appointment for that day will be cancelled. If Marywood University is on a delayed

schedule, therapy sessions will begin when classes resume.

(E.g., If classes are delayed and will resume beginning at 10am, then therapy sessions beginning on or after 10am will

resume as well.)

6. Clinic Rooms

The Student Preparation Room is available for all student clinicians. Student clinicians are responsible for maintaining the

order and cleanliness of this room. As space is limited, the room cannot be used for storage of personal belongings. All

therapy/diagnostic materials are to be returned to the appropriate shelves when not in use.

Clinic rooms are available for testing and therapy purposes. Student clinicians are responsible for leaving the clinic rooms

in order (e.g., cleaning furniture after each treatment/diagnostic session, lights shut off, doors closed, cleaning supplies

replenished, etc.)

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7. Clinic Telephone Usage

If a telephone call regarding a client must be made, the student clinician may request to use a clinical supervisor’s

telephone, or utilize the phone located in the locked computer lab secondary to privacy issues. Phone calls made on all

CSD Department telephones are monitored with a printout received by the Department Chairperson.

8. Emergency Protocol

In case of a medical emergency during a therapy or diagnostic session, the following protocol should be followed:

A. Attend to the individual’s immediate safety and comfort needs.

B. Clear the area of any obstacles, such as furniture or equipment, in close proximity to the individual.

C. Ask a clinical supervisor, faculty member, or student to call 911 and initiate emergency medical services.

D. Marywood University security personnel should also be informed of the emergency by dialing 348-6242.

In case of fire, escort the individual to the nearest exit and wait outside the building with the person until re-entry clearance

is given. Close all doors and shut off lights when exiting a room.

9. Universal Precautions

Universal measures are to be followed by all clinicians working in the clinic area. These regulations include washing your

hands before and after the therapy session, wiping of the tables and toys that were used that session, wearing gloves when

working with clients (primarily oral motor, when you will be working in/near the client’s mouth), as well as providing for a

safe working space for you and your clients.

10. Inservices

Student clinicians are required to attend at least one scheduled in-service of their choice per semester unless the clinic

director scheduled it as mandatory. Failure to do so will result in the overall clinic grade for that semester being lowered by

one letter grade.

11. Research

Student clinicians are required to complete Evidence Based Practice (EBP) assignments throughout their on campus

practicum experiences. An informational inservice, literature review and relevant research are assigned within various

semesters. Completion of EBP research should be geared toward use with the client in a functional way (e.g., a new therapy

technique, behavior modification systems, etc.) and should be completed by the date specified by individual clinical

supervisors and/or the semester clinic memo (generally within the first two weeks of the semester). Late submission of

research (i.e. after the 2 week timeline) will result in a 0.1 point deduction off your clinic grade for the semester. If research

is submitted within the established timelines, but requires resubmission due to the appropriateness of the submission,

students are allowed one resubmission without any deduction of points. If two resubmissions are needed, the student will

have 0.1 points deducted from his/her grade for the semester. Any resubmissions beyond that will be treated in the same

manner as if the research had not been submitted at all (see below for deductions). Failure to complete research will result

in the overall lowering of the clinic grade for the semester by one letter grade for each instance that the research was not

completed (i.e. if research was not completed for 2 clients and the initial grade was a B+, the overall clinic grade would be

lowered to a B-). It is at the discretion of each clinical supervisor to accept/reject the clinical research based on the

appropriateness in relation to the client.

11. Flash Drives

Student clinicians will be given a departmental flash drive to save any client specific information for the time that they are

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completing an on-campus clinical practicum. Flash drives will be returned to individual supervisors at the end of each

semester for deletion of client information and then given back to student clinicians for the following semester. Flash

drives will eventually be returned to supervisors at the end of all on-campus practicums. Failure to return a flash drive or

returning the flash drive in a damaged condition will result in withholding the clinic grade and possible responsibility of the

student clinician to replace, if the damage if due to the student’s negligence. Please note that when not in direct use, flash

drives are to be kept in the locked cabinet in the clinical preparation room. They are only to be used for clinical

documentation in the clinical preparation computer room located in McGowan 1052. They are never to leave the previously

listed area unless you are bringing to a supervisory meeting. If violations to this policy occur, students will be subject to the

procedures as listed in the CSD conduct policy.

13. Cleaning Procedures

Student clinicians will be assigned on a rotating basis to various cleaning duties at the end of each week. Cleaning is to be

completed for the diagnostic materials, therapy materials, playroom, toy closet, therapy rooms, Speech Science (Room

1085) and clinical preparation room. Cleaning of the assigned areas is to take place either on Thursday after the clinic

closes or on Fridays. When your assigned cleaning duty is completed you are to inform one of the clinical supervisors so

that they can sign off that the duty has been satisfactorily completed. Failure to complete your assigned duty by the end of

the day on Friday will result in three things: 1) You will still complete the assigned duty ASAP 2) You will be assigned an

additional week of cleaning towards the end of the semester 3) You will have 0.2 points deducted from your overall clinic

grade at the end of the semester for each missed cleaning assignment.

14. Anti-Discrimination Policy

Marywood University (the “University”) declares and reaffirms a policy of

equal educational and employment opportunity and non-discrimination in its educational programs and all other activities

that it operates both on and off University property. Marywood University does not condone and will not tolerate

discrimination, harassment, or assault by any member of the faculty, staff, administration and student body as well as

volunteers on and visitors to the University upon another individual, regardless of whether the action is based on race, sex

(including sexual harassment and sexual violence), color, gender, national or ethnic origin, age, creed, ancestry, religion,

disability, or any other legally protected status.

Please see web-address for Marywood University's Anti-Discrimination Policy in its entirety:

http://www.marywood.edu/studenthandbook/policies-and-procedures/index.html?id=247053&crumbTrail=Anti-

Discrimination%20Policy&pageTitle=Anti-Discrimination%20Policy

Failure to comply with any clinic policy and/or procedure will result in referral to the CSD Department

Chairperson, Master’s Program Director, and Clinic Director, which may result in academic probation or dismissal

from the pre-professional (undergraduate) or professional (graduate) program.

http://www.marywood.edu/studenthandbook/policies-and-procedures/index.html?id=247053&crumbTrail=Anti-Discrimination%20Policy&pageTitle=Anti-Discrimination%20Policy

http://www.marywood.edu/studenthandbook/policies-and-procedures/index.html?id=247053&crumbTrail=Anti-Discrimination%20Policy&pageTitle=Anti-Discrimination%20Policy

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MARYWOOD UNIVERSITY



Client Folder Sign Out Log

Date Student Clinician Client Initials Time Signed

Out

Time

Returned

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MARYWOOD UNIVERSITY



Clinic Materials Sign Out Log

Date Student Clinician Materials Borrowed Time Signed

Out

Time

Returned

Documents

MARYWOOD...CSD 521 Supervised clinical practice in the principles and procedures necessary for assessment of speech and language disorders with various populations at the Marywood