Speech-Language Pathology Clinical Fellowship (SLPCF) Report and Ratings Form: How to Avoid Common Errors
What you need to know first:
- All academic coursework and practicum hours must be completed before beginning your Clinical Fellowship (CF) experience.
- Before initiating the CF, and periodically throughout the CF experience, check online to ensure your mentor is currently certified.
- Professional experience of less than five hours per week cannot be used to meet the SLPCF requirement.
- Overlapping dates across separate CF forms will only be counted once; all hours with overlapping dates will be counted.
- Alternative methods of supervision (i.e., remote or telesupervision) may not be used without prior approval by the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC).
Section 1. Speech-Language Pathology Clinical Fellow Information
Complete the entire section, including signature and date. If you have a NSSLHA number, put that in place of the ASHA account number.
Section 2. SLPCF Mentor Information
The mentor must sign and date this section and include his/her ASHA account number.
Section 3. SLPCF Setting Information
- Only one facility name is required. If you work for a contract agency or school district, enter the agency/district for facility name.
- Each CF mentor must complete a separate SLPCF Report and Ratings Form.
Section 4. SLPCF Duration (Beginning and Ending Dates)
If there is more than one mentor or setting, ensure the start/end date and number of weeks worked reflects the time spent with that mentor, not the entire CF experience.
Section 5. SLPCF Activity Information
- Enter the number of hours you typically worked per week in each category.
- A full-time CF is at least 35 hours per week.
- Ensure that 80% of clinical contact hours are related to the management process of individuals who exhibit communication difficulties. Weekly hours that include “other activities” such as in-service training and/or presentations cannot exceed 20% of the total hours per week.
- Ensure activities in Section 5 are listed in hour format and add up to the total hours per week.
- Do not include lunch and travel time in your total hours worked.
Section 6. SLPCF Skills Rating Chart Instructions for the SLPCF Mentor
- Ensure the segment dates are in mm/dd/yy format (e.g., 05/05/18).
- All skills must be rated at least once during the CF and all skills must have a rating in segment 3, other than those marked N/A.
- Ensure the mentor and the CF sign under each segment and enter a feedback session date. If you have multiple mentors, each mentor needs to complete and submit a separate 2-page SLPCF Report and Rating Form.
Section 7. SLPCF Mentor's Recommendations and Verification of Information
The CF mentor must answer all three questions in Section 7, even if this is a part-time report or a separate report. Their responses are only for this SLPCF Report and Ratings Form. If there is a negative response to any of the questions, the mentor must provide a signed and dated explanation.
Section 8. Signatures of SLPCF Mentor and SLP Clinical Fellow
Mentors and Clinical Fellows cannot sign off on the SLPCF Report and Ratings Form until the CF experience has ended.
SLPCF General Information
- Keep a copy of this form for your personal records.
- Please complete and submit both pages of the SLPCF Report and Ratings Form [PDF].
- You may scan your completed SLPCF Report and Ratings Form(s) and submit in PDF format via email to email@example.com.
- If corrections need to be made, please email the updated documents in PDF format to firstname.lastname@example.org. Both pages must be submitted and the words "Corrected Forms" should be written over the top of the first page.