CERTIFICATE OF CLINICAL PRACTICE (CCP)
AWARD APPLICATION FORM
This form must provide information that documents the completion of an approved Clinical Internship
Program of supervised professional experience in clinical audiology.
PART 1
APPLICANT’S NAME: (Dr,Mr,Mrs,Ms,Miss): ……………………………………………………………….................................................................
(please print legibly)
Applicant’s Declaration:
I…………………………………………………….....................CERTIFY that I have completed the Clinical Internship program of supervised
professional experience, as detailed in my Knowledge & Skills Matrix and Supervision Agreement and approved by Audiology
Australia Ltd and I have attached supporting documentation as follows:
Balance of Supervision Diary OR 2 Case Studies
Supervisor’s final evaluation
Completed Knowledge & Skills Matrix
Intern’s Reflective Statement
Workplace:
Name:……………………………………………………………………………………………………………………………...............................................................
Address:……………………………………………………………...............................................Suburb.......…………………………….Postcode…………...
Email:………………………………………………....................................................Phone:………………………….......Fax:……………………………………
Applicant’s Signature: ......................................................................................................
Date: ......../............/.........
PART 2
Supervisor’s Declaration:
I CERTIFY that:
1.
………………………………………………………………………....(Applicant’s name) has completed the Clinical Internship Program in
accordance with Audiology Australia Ltd’s Clinical Internship Guidelines and has, in my opinion, reached a level of
professional preparation such as may be expected to enable him/her to perform clinical services in audiology
competently and without supervision by persons with more education and/or experience.
2.
I have held a current Certificate of Clinical Practice continuously for the whole period of supervision and have directly
supervised this professional experience as per the Requirements for Supervisors of the Clinical Internship Program for
the award of the Certificate of Clinical Practice.
Supervisor’s Signature: ....................................................................................................
Date: ........./............/...........
Name and designation (print legibly): ................................................................................................................................
Please email all completed documentation to:
internship@audiology.asn.au
Audiology Australia Ltd
PO Box 504, Brentford Square, Vic 3131
CCP Award Application – v.4