Asha Hours Form Summer 2014
Asha Hours Form Summer 2014
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Asha Hours Form Summer 2014
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Asha Hours Form Summer 2014
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UWW - ASHA HOUR FORM
Instructions for filling out the Workbook
1. Enter your contact hours for each client in the worksheets labled C (1) through C (10).
Hours must be in decimal notation. If you are not sure on how to convert minutes
to a decimal notation use the "min-decimal converter" worksheet.
2. Hour sheets must not be saved on lab computers.
3. Make sure that you backup your work. You will be updating the workbook each semester.
4. After updating the worksheets, print off a copy of the summary and all worksheets
that require a supervisor's signature.
If the sheet takes up more than one printed page go to the Page Setup Menu
and change the scaling to "Fit to: 1 page tall and 1 page wide"
5. Be sure to turn in signed copies of your hours worksheets and summary
to the clinic supervisor.
6. You may change to name of the worksheets by double clicking on the tab at the
bottom of the sheet and typing in a new name.
For example, you can change C (1) to read Spring 04 - <supervisor's name>
Use this Worksheet to convert minutes to a decimal notation.
minutes
60
59
58
57
56
55
54
53
52
51
50
49
48
47
46
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
decimal
equivalent
1.00
0.98
0.97
0.95
0.93
0.92
0.90
0.88
0.87
0.85
0.83
0.82
0.80
0.78
0.77
0.75
0.73
0.72
0.70
0.68
0.67
0.65
0.63
0.62
0.60
0.58
0.57
0.55
0.53
0.52
minutes
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
decimal
equivalent
0.50
0.48
0.47
0.45
0.43
0.42
0.40
0.38
0.37
0.35
0.33
0.32
0.30
0.28
0.27
0.25
0.23
0.22
0.20
0.18
0.17
0.15
0.13
0.12
0.10
0.08
0.07
0.05
0.03
0.02
ASHA HOUR FORM - SUMMARY - UW WHITEWATER
STUDENT NAME:
Allison Zimmerman
SEMESTER/YEAR:
Summer 2014
Birth to 3
>3 to 6
>6 to 12 >12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
0
5.413
2.25
0
0
0
4.5
32.25
23.163
0
0
4.5
Articulation
evaluation
intervention
Fluency
evaluation
intervention
0
0
0.5
0
0
0
0
0
0
0
Voice and
Resonance
evaluation
intervention
0
0
0
0
0
0
0
0
0
0
1.5
6.92
0
4.42
0
0
0.166
1.75
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
On-Campus Off-Campus
Hours
Hours
Total Hours
by Category
6.833
38.413
0.83
21.5
7.663
59.913
0
0
0.5
0
0
0
0.5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1.5
0
0
11.34
1.5
11.34
0
2.75
2.75
14.25
0
0
0
0
2.916
16
0
2.75
2.916
18.75
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
5.92
0
0.17
0
0
0
0
0
0
0
2.42
0
3.67
0
Swallowing
evaluation
intervention
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
1.25
10.84
0
2.42
0
2
0
0
1
0
1.25
3.75
0
11.51
Social Aspects
of Communication
evaluation
intervention
0
0
0
5.42
0
2.42
0
1
0
0
0
0
0
0
0
8.84
0
8.84
AAC Assistive
Technology
evaluation
intervention
0
0
0
0
0
2.5
0
14
0
6
0
0
0
16
6.5
0
0
22.5
Summary of Hours by Age & CLD
4.5
71.929
40.093
34
6.5
89.582
66.94
Total Number of Hours
156.522
Student Signature __________________________________________________
Date:
Clinic Coordinator
Signature
Date:
__________________________________________________
ASHA Acount Number ______________________
(revised 5/15/2013/sb)
6.09
0
0
0
1.25
15.26
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: Williams Bay Elementary
Semester/Year/
Supervisor
Fall/2013/Dana Syring
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
0.83
3
10.33
3
2.5
On-CampusOff-Campus
Hours
Hours
Articulation
evaluation
intervention
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
0.83
16.33
Total Hours
by Category
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0.83
16.33
0
0
0
0
0
0
Hearing
evaluation
intervention
3.67
3.67
Swallowing
evaluation
intervention
Cognitive Aspects
of Communication
evaluation
intervention
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
0
0
2.67
Summary of Hours by Age & CLD
Total Number of Hours
23.5
17.5
2.67
2.5
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
3.67
0
ASHA Account Number: _______________
23.5
0
2.67
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: Washington Elementary School
Semester/Year/
Supervisor
Fall/2013/Melanie Lindstrum
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation
evaluation
intervention
1.5
1.67
On-CampusOff-Campus
Hours
Hours
5.17
Total Hours
by Category
0
5.17
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
2.5
2.5
2.75
2.75
0
2.5
0
2.75
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
1.5
Total Number of Hours
10.42
4.17
4.75
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
10.42
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: UWW-CCD
Semester/Year/
Supervisor
Fall/2013/Beth Miller Swanson
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
1.333
1
5.583
On-CampusOff-Campus
Hours
Hours
Articulation
evaluation
intervention
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
2.333
5.583
Total Hours
by Category
1.5
1.5
0.166
0.166
2.333
5.583
1.5
0
0.166
0
0
0
Hearing
evaluation
intervention
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
11.582
4.999
6.583
11.582
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
2
0
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: UWW-CCD
Semester/Year/
Supervisor
Spring 2014/Beth Miller Swanson
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
2
1.25
6.25
12.58
On-CampusOff-Campus
Hours
Hours
Articulation
evaluation
intervention
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
3.25
18.83
Total Hours
by Category
3.25
18.83
0
0
2.75
14.25
1.75
2.75
16
2.75
16
0
0
Hearing
evaluation
intervention
0.17
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
41
10
14
0.17
17
41
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
0.17
0
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: Janesville Extended School Year
Semester/Year/
Supervisor
Tracy Schenk
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
4.42
4.42
8.84
0
8.84
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
4.42
2.42
8.84
0
8.84
Social Aspects
of Communication
evaluation
intervention
5.42
2.42
8.84
0
8.84
AAC Assistive
Technology
evaluation
intervention
2.5
11.76
6.5
Summary of Hours by Age & CLD
Total Number of Hours
33.02
14.26
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
33.02
0
6.5
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: UWW CCD
Semester/Year/
Supervisor
Summer/2014/Beth Miller Swanson
Articulation
evaluation
intervention
Fluency
evaluation
intervention
Voice and
Resonance
evaluation
intervention
Receptive and
Expressive
Language
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
1.25
14
0.5
On-CampusOff-Campus
Hours
Hours
1.25
14
Total Hours
by Category
1.25
14
0.5
0.5
0
0
0
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0.25
0.25
Swallowing
evaluation
intervention
Cognitive Aspects
of Communication
evaluation
intervention
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
0
0
1.25
3.75
Summary of Hours by Age & CLD
Total Number of Hours
21
21
1.25
3.75
21
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
0.25
0
ASHA Account Number: _______________
1.25
3.75
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Allison Zimmerman
Practicum Setting: UWW - Campus/ Authentic Voices of America Camp
Semester/Year/
Supervisor
Summer/2014/Valerie Hoehnke
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
Summary of Hours by Age & CLD
Total Number of Hours
16
10
10
16
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
0
16
16
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
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intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
Birth to 3
>3 to 6
>6 to 12
>12 to 18
Adult
CLD*
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
On-CampusOff-Campus
Hours
Hours
Total Hours
by Category
Articulation
evaluation
intervention
0
0
Fluency
evaluation
intervention
0
0
Voice and
Resonance
evaluation
intervention
0
0
Receptive and
Expressive
Language
Speaking/Listening
evaluation
intervention
Writing/Reading
evaluation
intervention
Manual
evaluation
intervention
0
0
0
0
0
0
Hearing
evaluation
intervention
0
0
Swallowing
evaluation
intervention
0
0
Cognitive Aspects
of Communication
evaluation
intervention
0
0
Social Aspects
of Communication
evaluation
intervention
0
0
AAC Assistive
Technology
evaluation
intervention
0
0
Summary of Hours by Age & CLD
Total Number of Hours
Student Signature __________________________________________________
Date: ______________
Supervisor Signature __________________________________________________
Date: ______________
ASHA Certification:
SLP
ASHA Account Number: _______________
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