Revised Fall 2015
SLP/A Clinic Committee

Institutional Mission
Department Mission
Introduction
Clinical Responsibilities
Clinical Supervisor
Student Clinician
Attendance Policy
Clinician Absences
Client Cancellations
Make-up Sessions
Confidentiality
Professional Dress and Manner
Professional Competency
Clinical Remediation Plan
Medical Clearance
International Students
Client Rights and Responsibilities
ASHA, HIPAA, IDEA, and ADA information
Liability
Clinical Assignments
Observation Assignments
Therapy
Speech, Language, and Hearing Screenings
Speech and Language Diagnostics
General Information and Daily Procedures
Client Files
Client Working Files
Off-campus Documentation
Therapy Sessions- Assigned Rooms/No Shows
Snow/Weather Emergencies
Holidays
Clinic Materials
Video Recording
Nametags
Clinical Forms and Reports
Safety, Medical Emergencies, and General Information
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Safety of Clients
Medical Emergency
Injury
Client/Clinician Leaving the Clinic
General Emergency Procedures
Universal Precautions
Client health status
Gloves
Hand Washing
Clinician Absence Form
Confidentiality Policy
Permission for Food
Clinical Remediation Plan
Client Rights
Client and Family Responsibilities
New Assignment Form
Log Sheet of Clock Hours
Evaluation Consent Form
Release of Information From Clinic
Speech Evaluation Charge Form
Therapy Schedule Request Form
Diagnostic Report Template
Inserting Phonetic Symbols into Word Documents
Student Evaluation of Diagnostic
Request for Client File
Student Evaluation of Treatment
Treatment/Program Plan Template
Clock Hours Summary Form
Therapy Attendance Record
Telephone Consultation Log
Treatment Consent Form
Release of Information to Clinic
Daily Materials Sign Out
Overnight Materials Sign Out
Progress Report Template
Log Sheet of Therapy Observation
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A18
A19
A20
A21
A22
A23
A24
A25
A26
A27
A8
A9
A10
A11
A12
A13
A14
A15
A16
A17
A1
A2
A3
A4
A5
A6
A7
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To provide a foundation for a lifetime of learning, Ithaca College is dedicated to fostering intellectual growth, aesthetic appreciation, and character development in our students.
The Ithaca College community thrives on the principles that knowledge is acquired through discipline, competence is established when knowledge is tempered by experience, and character is developed when competence is exercised for the benefit of others.
A comprehensive college that since its founding has recognized the value of combining theory and performance, Ithaca provides a rigorous education blending liberal arts and professional programs of study. Our teaching and scholarship are motivated by the need to be informed by, and to contribute to, the world's scientific and humanistic enterprises.
Learning at Ithaca extends beyond the classroom to encompass a broad range of residential, professional and extracurricular opportunities. Our undergraduate and graduate students, faculty, staff and alumni all contribute to the learning process.
Ithaca College is committed to attracting a diverse body of students, faculty and staff. All members of the College community are encouraged to achieve excellence in their chosen fields and to share the responsibilities of citizenship and service in the global community.
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The mission of the department is five-fold.

Educate undergraduate students and graduate students seeking a communication disorders program that is accredited by the Council on
Academic Accreditation in Audiology and Speech Pathology and the New
York State \Regents Accreditation of Teacher Education;

Prepare students in a professional, clinical discipline within a liberal arts framework that assists them in the development of independent functioning and critical thinking through the provision of academic, clinical, and research experiences;

Provide a firm theoretical foundation and opportunities for application of theory to practice leading to the development of competence, confidence, and contributing professionals qualified for certification by the appropriate professional groups;

Contribute a valuable and high - quality professional service to the community; and

Contribute to the body of knowledge in the field of speech-language pathology.
The mission of the clinical program at Ithaca College is to provide students appropriately supervised clinical experiences sufficient in breadth and depth to help them develop the following diagnostic, therapeutic, and interpersonal knowledge and skills:

The ability to conduct screening and prevention procedures;

The ability to collect accurate and pertinent case history information and integrate information from clients/patients, family, caregivers, teachers, and other professionals;

The ability to select and administer appropriate evaluation procedures such as: behavioral observations, standardized and non-standardized tests, and instrumental procedures;

The ability to adapt evaluation procedures to meet client/patient needs;

The ability to interpret, integrate, and synthesize all information in order to develop diagnosis and make appropriate recommendations for intervention;

The ability to complete administration and reporting functions necessary to support the evaluations;

The ability to refer patients for appropriate professional services;
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
The ability to develop, in collaboration with clients/patients and relevant others, setting-appropriate intervention plans with measurable and achievable goals that meet the clients’/patients’ needs;

The ability to implement intervention plans while involving clients/patients and relevant others in the intervention process;

The ability to select or develop and use the appropriate materials and instrumentation for prevention and intervention;

The ability to measure and evaluate the clients’/patients’ performance and progress;

The ability to modify intervention plans, strategies, materials, or instrumentation as appropriate to meet the needs of clients/patients;

The ability to complete administrative and reporting functions necessary to support intervention;

The ability to identify and refer clients/patients for services as appropriate;

The ability to communicate effectively, recognize the needs, values, preferred mode of communication, and cultural/linguistic background of the client/patient, family, caregivers, and relevant others;

The ability to collaborate with other professionals in case management

The ability to provide counseling regarding communication and swallowing disorders to clients/patients, family, caregivers, and relevant others; and

Knowledge of the ASHA Code of Ethics and the importance of professional behavior
It is the goal of the clinical program at Ithaca College to help students develop the above knowledge and skills with children and adults in the areas of:
 articulation;
 fluency;
 voice and resonance, including respiration and phonation
 receptive and expressive language (phonology, morphology, syntax, semantics, pragmatics, pre-linguistic communication, and paralinguistic communication) in speaking, listening, reading, and writing
 hearing, including the impact on speech and language
 swallowing (oral, pharyngeal, esophageal, and related functions, including oral function for feeding, orofacial mycology)
 cognitive aspects of communication;
 social aspects of communication; and
 augmentative and alternative communication modalities
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The Sir Alexander Ewing-Ithaca College Speech and Hearing Clinic is an integral part of the Department of Speech-Language Pathology and Audiology at Ithaca College. The
Clinic offers upper level undergraduate and graduate students the opportunity to gain clinical experience under the guidance and close supervision of American Speech-
Language-Hearing Association (ASHA) certified speech-language pathologists and audiologists.
The services in the Clinic include the diagnosis and (re)habilitation of speech, language and hearing problems. The disorders are varied, with the population ranging from young children to adults. Clients are typically from the Tompkins County area and the Ithaca
College community. Various off-campus clinical placements are also offered.
This manual is a guide for students enrolled in Clinical Practicum within the Department of Speech-Language Pathology and Audiology. Clinicians should be thoroughly familiar with the procedures, policies regarding the provision of services, and clinical responsibilities expected of them while working in the Clinic or off-campus.
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The graduate programs in Speech Pathology and Audiology at Ithaca College are accredited by the Council of Academic Accreditation of the American Speech-Language-
Hearing Association (ASHA) and the National Council for Accreditation of Teacher
Education (NCATE). The Department of Speech-Language Pathology and Audiology has adopted the position statement, “Clinical Supervision in Speech-Pathology”
( http://www.asha.org/policy/PS2008-00295/ ). The position statement delineates tasks of a clinical supervisor and defines the competencies needed by supervisors in carrying out these tasks. Students may refer to this position statement to better understand the role of a clinical supervisor in their clinical practicum experience within the Department of
Speech-Language Pathology and Audiology. Information regarding position statements, policies and procedures of ASHA can be found at www.professional.asha.org
. The following is a brief summary of what the student may expect from his/her supervisor and to understand competencies expected of each student.
The supervisor is responsible for guiding the student’s clinical learning experiences.
Some of the goals of the supervised clinical experience are to allow opportunities for the student to learn to:

Develop appropriate goals and strategies for evaluation and therapy.

Develop lesson plans that utilize appropriate procedures and materials for achieving therapy goals.

Develop skill in utilizing a variety of clinical techniques.

Develop clinical writing skills.

Develop the ability to evaluate his/her own strengths and weaknesses as a clinician.
In order to achieve the above goals, the supervisor functions in the following ways:

Observes the student clinician as he/she conducts therapy, screenings, and evaluations. (ASHA guidelines: 25% of the total number of client contact hours)
See 2014 Standards for Certificate of Clinical Competence: http://www.asha.org/Certification/2014-Speech-Language-Pathology-
Certification-Standards/

Provides the clinician with formative feedback, written and/or oral, about observations, adequacy of therapy plans, written reports, case conferences and other aspects of clinical practice.

Consults with the clinician regarding problems as needed.

Suggests alternative procedures for implementing goals.
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Facilitates the development of report writing skills.
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Demonstrates, where necessary, therapy techniques by working directly with the client.

Participates in family and client case conferences. Insures that family and caregivers participate in the intervention process.

Gives the clinician support with the ultimate goal of independent functioning.

Provides to the student documentation of clinical performance at midterm
(oral and/or written) and written comprehensive summative assessment at semester’s end

Complies with the privacy, security, and safety requirements of the Ewing
Clinic
The following should be considered as minimum standards for participating in clinical practicum:

Full knowledge of the information in the Clinic Manual

Timeliness, preparedness, and accountability to all activities related to the clinic process

Conducting oneself professionally

Compliance with the privacy, security, and safety requirements of the Ewing
Clinic
It is suggested that you arrive at the clinical placement at least 15 minutes prior to your scheduled session. You should allow this time for gathering and checking out materials.
Lateness for a scheduled appointment will not be tolerated.
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Consistent with the Ithaca College Student Handbook, attendance is required at all clinical assignments. Verifiable illness, personal emergencies, and religious Holidays are excused absences.
Ewing Clinic Absences:
In these cases the student clinician will contact the administrative professional, the college supervisor, and the Clinic Director. A response from at least one of these individuals is required before the session is considered cancelled. In most cases the administrative professional will then contact the client. However, in the rare exception where a response is not received within a reasonable time frame, it will then be the student clinician’s responsibility to make direct contact with the client to confirm cancellation.
Off-Campus Absences:
In these cases the student clinician will contact the off-campus supervisor and the
Ewing Clinic Director. A response from at least one of these individuals is required before the session is considered cancelled. The clinician should also follow any off-campus site policy regarding absences.
General Absence Information:
Clinicians should notify their supervisor at least one week before any anticipated absence. In this scenario, it is the student’s responsibility to ensure that the client is informed of the cancellation.
All absences require completion of the Clinician Absence Form (see A1). This is to be turned in to the Clinic Director upon return of absence. Failure to provide notification of an absence, will likely result in a warning and may result in a grade reduction.
An attempt should be made to make up the sessions that are cancelled.
Cancellations by the client: If appropriate, an effort should be made to make up sessions cancelled by the client. Make-up sessions must be approved by the supervisor and the administrative professional must be consulted to ensure room availability.
Cancellations by the student clinician: When a student clinician cancels a session, the student is required to submit a proposed make up plan (see A1) as soon as possible after the cancellation occurred. Make-up sessions must be approved by the supervisor and the administrative professional must be consulted to ensure room availability.
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All information concerning clients being seen at the clinic or at off-campus programs is to be considered protected health information (PHI). All students, faculty members, employees, visitors, volunteers, or affiliates of the Ewing Clinic must comply with federal legislation, including the Health Insurance Portability and
Accountability Act (HIPAA), requiring full disclosure of client rights, and written consent to disclose or obtain information.
All students involved in clinical practicum must sign a confidentiality agreement (see A2) and show competency in privacy, security, and safety regulations (see Sakai modules on
HIPAA and safety).
Clinic folders, or any materials in them, should not be taken from Smiddy Hall or left unattended at any time. They are to be returned to the administrative professional before 4:45pm. Any deviation from this policy is considered a breach of protocol and may result in disciplinary action.
Student clinicians who are meeting the public (directly or indirectly) in a professional capacity are to dress appropriately. In general, dress for professional purposes is conservative, not distractible to clients, and does not draw attention to itself. Please note the following guidelines:

All clothing must be maintained in good repair.

No crop tops, low cut shirts or exposed midsections or cleavage baring necklines.
 No jeans or “low rider” pants that expose midriff or lower back.

Skirt lengths should be conservative.

No athletic clothing.

Large logos and insignias on shirts are prohibited.

Appropriate shoes must be worn at all times. Flip-flops or similar footwear are not allowed.

Conservative jewelry is allowed.

Tongue, lip, or other oral piercings are unacceptable. Acceptability of other body piercings is at the discretion of the supervisor.

Proper personal hygiene
Dress for both on-campus and off-campus placements should be at the discretion of the site supervisor and appropriate for the individual location.
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If you are unsure about a particular article of clothing, it is best not to wear it. Your supervisor has the authority to send you home to change if your attire does not meet approval.
Formal methods of addressing faculty are to be used in the Clinic. Supervisors are to be addressed as Dr., Mr., Mrs., Ms., and Miss.
Students may want to discuss with their supervisor how they would like to be addressed in the clinical setting.
Food and drinks should only be allowed in the treatment rooms in the context of treatment. These items are not allowed near computers and equipment. Student clinicians should get the permission form (see A3) signed by parents prior to giving any child food or drink.
The student clinician is expected to demonstrate competency relative to his/her academic and clinical experience. In the event a student does not demonstrate competency a clinical remediation plan will be developed.
Clinical Remediation Plan
As required by the Council of Academic Accreditation and the Council for
Clinical Certification, students must demonstrate knowledge and skills in prevention, assessment and intervention across the professional scope of practice.
By completion of the second fulltime fieldwork experience, students should demonstrate clinical competencies that are appropriate for entry into the profession. Should student performance not meet expectations, a clinical remediation plan may be implemented. The clinical remediation plan document
(see A4) identifies the area(s) of concern and defines the remediation strategy.
The clinical supervisor initiates the clinical remediation plan and develops it in consultation with the SLP Clinic Director and/or Fieldwork Coordinator.
Medical Clearance
Some outside clinical placements require proof of recent physical and TB (within one year) and/or other forms of medical clearance. Services can be provided at
Hammond Health Center or by a private practitioner. Students are responsible to ensure compliance.
International Students
International students are not allowed to work or volunteer at off campus sites without approval from the office of international studies. It is the student’s responsibility to identify themselves as an international student to both the clinical director and clinical supervisor and to comply with all required documentation.
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General competency information

Knowledge and compliance of Client Rights and Responsibilities at the Sir
Alexander Ewing Ithaca College Speech and Hearing Clinic (see A5 and A6).

Students are encouraged to visit the ASHA website for current information regarding professional issues, resources, standards, continuing education, etc. www.asha.org

Adherence to the ASHA Code of Ethics and the Ithaca College Student Code of Conduct (Ithaca College Student Handbook) is required. http://www.asha.org/Code-of-Ethics/

Understanding the Scope of Practice in Speech-Language Pathology and
Audiology:
SLP: http://www.asha.org/policy/SP2007-00283.htm
Audiology: http://www.asha.org/policy/SP2004-00192.htm

Familiarity with legislation that affects the provision of services, including
HIPAA, Individuals with Disabilities Education Act (IDEA), and Americans with Disabilities Act (ADA) is also required. See the following websites: www.nichcy.org
www.usdoj.gov/crt/ada www.asha.org
.

All students engaged in direct client contact are automatically placed on the college’s liability policy and are billed accordingly.
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Observation Assignments

Student observers must adhere to the ASHA Code of Ethics: http://www.asha.org/Code-of-Ethics/

Observation assignments are obtained in your clinical observation course.
You should log each observation minute on a log sheet of therapy observation form (see A27)

Be respectful of clinic property and equipment
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Adhere to HIPAA guidelines regarding client confidentiality
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There is a limit of 4 individuals to each observation room
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Family and supervisors must have priority access to observe sessions.

If you experience a technical problem with any of the AV equipment, please notify the administrative professional.

Do not interrupt therapy sessions for signatures from the student clinician until the client has left the clinic.
Speech, Language, and Hearing Screenings

Notifications for screenings will be emailed to your ithaca.edu email address.
If training or consultation is needed prior to the screening, contact the assigned supervisor.

Students assigned to the screening are responsible for signing out and bringing the necessary materials (test, forms, equipment) to the screening.

A log sheet of clock hours (see A8) should be completed for each screening.
Be sure the appropriate supervisor signs the sheet at the end of each day.
Speech and Language Diagnostics

The Clinic Director schedules assignments for speech and language evaluations. Notifications for diagnostics will be emailed to the student clinician and clinical supervisor at their ithaca.edu email at least one week in advance of the scheduled diagnostic appointment.

The student clinician should review the client’s folder and begin to plan the diagnostic evaluation. It is the student’s responsibility to arrange a meeting with the supervisor to discuss and plan the evaluation. This meeting should take place at least 72 hours before the evaluation.
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The interview/diagnostic is to be video recorded. THE STUDENT
CLINICIAN IS RESPONSIBLE FOR MAKING THESE
ARRANGEMENTS.
(see General Information)

Before beginning the interview/diagnostic, the student must have the client or legal guardian review and sign the appropriate consent form (see A9). This gives permission to do the evaluation, to video record, audio record, and have observers. The form should be in the client’s file the day of the evaluation.

The client or legal guardian must sign the authorization for release of information to a third party (see A10). Return the signed form to the administrative professional to be placed in the client’s folder.

The supervisor must be available during the diagnostic, in compliance with the CAA guidelines.

The results of the evaluation will be summarized at a meeting with the client and/or legal guardian, to be held at the conclusion of the diagnostic or at another date and time, if needed.

The student clinician should complete A Speech Evaluation Charge/Follow
Up sheet (see A11) and give it to the administrative professional at the conclusion of the diagnostic session.

If therapy is recommended, the client or legal guardian must complete a therapy schedule request form (see A12) and give it to the administrative professional for therapy coordination.

The initial draft of the evaluation, typed in Times New Roman (12 pt), is given to the supervisor within three (3) working days of the diagnostic. See the Appendix for the diagnostic report template (see A13) and how to insert phonetic symbols (see A14). The clinical supervisor will review the report and make any necessary comments regarding revisions. The report will be returned to you for corrections. Each revision should be resubmitted to the supervisor with the attached drafts within three (3) working days.

Once the clinical supervisor approves the report, the student clinician will submit a de-identified copy via email to the administrative professional for formatting and printing. Once formatted, the report will be proof-read and once it is determined to be error-free, the student clinician will obtain the appropriate signatures. The administrative will send a copy of the report to the client and/or legal guardian and the original will be placed in the permanent clinic folder.
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The entire process should take no more than 10 working days from the date of the evaluation.
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Off-campus sites have specific formats and procedures that reflect the needs of that location and site supervisor.
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The supervisor will complete a formative evaluation (see A15). This information is used in determining the clinic grade.
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A clock hour sheet, signed by the appropriate supervisor, should be completed for each diagnostic (see A8).
Therapy

Notifications for your therapy assignments will be emailed to your ithaca.edu email address.

NOTE: The schedule may be modified during the semester. Student clinicians and clinical supervisors will be notified of any changes.

For students assigned to the Ewing-Ithaca College Clinic, the student clinician should read the assigned client’s folder as soon as possible after the assignment has been made in order to familiarize himself/herself with the case history, previous therapy, etc. The first therapy session is planned with the supervisor’s guidance. An appointment for this initial case conference should be made within a reasonable time prior to the first therapy session.
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Permanent Client Files for Ewing-IC Clinic Clients
Client files are located in the file cabinets behind the clinic administrative professional. A client file request (see A16) form must be completed and given to the administrative professional who will get the file for the student clinician. The student clinician will return the file to the administrative professional for re-filing.
Files are never to be taken from the building or left unattended. All files must be returned by 4:45 pm.
Order and Content of Permanent Files:
The administrative professional is responsible for the order and content of permanent client files. The information should be filed in the following order:
Left side: Ewing Clinic generated speech/language reports (diagnostic,
treatment plans or progress), test forms corresponding to the
report; consent forms; in reverse chronological order.
Right side: control form; case history form; other allied reports; doctor
orders; previous treatment; audiology reports; professional
correspondence.
Client’s Working File
Ewing clinic assignments require the maintenance of a work file for organization and access to current treatment information. Files must not contain PHI, in accordance with the privacy and security policies of the Ewing Clinic.
Order and Content of Working Files:
The student clinician is responsible for the order and content of working client files. The information should be filed in the following order:
Left side: De-identified lesson plans for each session
Right side: De-identified SOAP notes for each session
Off-Campus Documentation
Students should refer to their off-campus supervisor for documentation requirements specific to their placement.
Therapy Sessions – Assigned rooms and No Shows
Therapy rooms, days, and times will be assigned at the beginning of the semester and must not be changed without checking with your supervisor, the Clinic
Director, and administrative professional.
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Therapy sessions are generally scheduled for fifty minutes. Strictly adhere to the time slot designated for therapy. Vacate your room and have it cleared of your materials within five minutes of ending the session.
If a client is late you must wait at least 15 minutes before assuming the client is not coming. Notify your supervisor and administrative professional prior to leaving the clinic.
Snow/Weather Emergencies
The Ewing Clinic follows the Ithaca City Schools for weather-related closings and delays. Please listen to the local radio or TV stations for announcements regarding closings. If the Ithaca schools are closed due to weather, the Clinic will be closed.
Holidays
At the Ithaca College Ewing Speech and Hearing Clinic the clinic schedule will follow the college calendar for holidays. At off campus sites, such as schools, the student clinician will follow BOTH the college’s academic calendar and the site’s calendar for holidays, early dismissals, and snow days.
Clinic Materials
Diagnostic and therapy materials, as well as audiology equipment, is available to students on a sign-out basis and are generally found in the Materials Room. The student clinician must sign out and return the materials with the student worker on duty (see A24). If the student worker is not available, please see the administrative professional. The student is responsible for any materials signed out under his/her name, or for replacement costs if not returned.
Test forms are obtained from the administrative professional. Unused forms are to be returned to the administrative professional for re-filing.
The clinic officially closes at 5:00 p.m.; therefore materials are to be returned to the student worker on duty by 4:50 p.m. Student clinicians who have 4:00 sessions are to return their materials immediately following their sessions.
Materials are allowed to be signed-out overnight and require the signature of a supervisor (see A25). The materials signed-out must be returned by the start of the next day’s therapy schedule, usually 9:00 a.m.
Video Recording
All diagnostics are video-recorded. Students or supervisors also may request recording of therapy sessions.
The student clinician is responsible for completing a request form, which can be found in the appropriately labeled mailbox outside the VTR room. The form should be submitted at least 24 hours before the requested recording time. Place
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the completed form in the “Video-record request” mailbox so the student worker for that day will know which sessions to record. Please note that a limited number of sessions can be recorded simultaneously. Check with the student worker prior to the session to be sure the request has been received and that the recording can be accommodated. When ready to begin the session, notify the student worker.
Use of personal video-recording devices and cameras/cell phones are prohibited.
Video-recordings are kept for a period of two weeks after recording has occurred.
If the recording is to be kept longer than this time span, note this on the request form and have it approved by a supervisor.
To view your video recording please see the student worker on duty. He/she will get the recording and set the monitor.
Nametags
Students enrolled in Clinical Practicum are required to purchase and wear nametags. An opportunity to purchase a nametag is given each semester.
Clinical Forms and Reports
Lesson Plans
Clinicians will prepare a lesson plan for each therapy session according to the format and time line provided by the supervisor. Consult with your supervisor regarding their personal lesson plan protocol.
SOAP Notes
Student clinicians will summarize each session using the SOAP format
(Subjective, Objective, Analysis, Plan). This must be completed prior to the next therapy session. Consult with your supervisor regarding their personal timeline and protocol.
Supervisor Observation Report
The supervisor provides the student clinician with verbal and/or written feedback when he/she observes a therapy or diagnostic session.
Student Evaluation Forms for treatment
The supervisor will complete a formative midterm and final evaluation (see A17).
This information is used in determining the clinic grade for each assignment.
Clinic grades are not based on the amount of client progress, but rather the degree
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of responsibility and clinical competence demonstrated by the student clinician throughout the semester.
Treatment/Program Plans
The initial draft of the treatment/program plan (see A18), typed in Times New
Roman (12 pt) is given to the supervisor two weeks after the initiation of therapy.
The clinical supervisor will review the report and make any necessary comments regarding revisions. The report will be returned to you for corrections. Each revision should be resubmitted to the supervisor with the attached drafts within three (3) working days.
Once the clinical supervisor approves the report, the student clinician will submit it via email to the administrative professional for formatting and printing. Reports must not contain PHI, in accordance with the privacy and security policies of the
Ewing Clinic. Once formatted, the report will be proof-read and once it is determined to be error-free, the student clinician will obtain the appropriate signatures. The administrative will send a copy of the report to the client and/or legal guardian and the original will be placed in the permanent clinic folder.
The entire process should take no more than 10 working days from the date of the evaluation.
Off-campus sites have specific formats and procedures which reflect the needs of that location and site supervisor.
Progress Reports
The initial draft of the progress report (see A26), typed in Times New Roman (12 pt) is given to the supervisor two weeks before the end of the semester. The clinical supervisor will review the report and make any necessary comments regarding revisions. The report will be returned to you for corrections. Each revision should be resubmitted to the supervisor with the attached drafts within three (3) working days.
Once the clinical supervisor approves the report, the student clinician will submit it via email to the administrative professional for formatting and printing. Reports must not contain PHI, in accordance with the privacy and security policies of the
Ewing Clinic. Once formatted, the report will be proof-read and once it is determined to be error-free, the student clinician will obtain the appropriate signatures. The administrative will send a copy of the report to the client and/or legal guardian and the original will be placed in the permanent clinic folder.
The entire process should take no more than 10 working days.
Off-campus sites have specific formats and procedures which reflect the needs of that location and site supervisor.
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Client and/or legal guardians will be given a copy of the report. If they have authorized any other individual or agency to receive a copy, please indicate that by entering a cc: line on the bottom of the report.
Client Contact Hours Forms
Client contact hours will be recorded on designated form (see A8).
The supervisor’s signature should be obtained immediately following each assignment
Students must make duplicates for their own files.
Summarize the content of all client contact forms for the semester on a summary sheet (see A19). Attach all client contact hour forms to this summary sheet and submit to the Clinic Director for verification.
Attendance Sheets
The student clinician is responsible for recording the client’s attendance and absences on form (see A20). At the end of each month, the student will submit this form to the administrative professional.
Telephone/Conference Log
Student clinicians will document telephone calls and conferences on a form (see
A21) and will submit it to the clinic administrative professional for placement in the file. A clinic telephone is available for student clinician use if preferred.
Supervision
Students should expect to be observed and receive feedback from their supervisor regularly in order to comply with ASHA requirement. Documenting amount of supervision is the supervisor’s responsibility.
Consent Forms
Before a client is evaluated an evaluation (see A9) consent form must be signed.
The student clinician is responsible for verifying that this form is signed and given to the administrative professional for filing in the permanent folder.
Before a client is seen for therapy a treatment consent form (see A22) must be signed. The student clinician is responsible for verifying that this form is signed and given to the administrative professional for filing in the permanent folder.
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Release of Information Forms
A release of information form from the Ewing Clinic (see A10) must be signed whenever the client/family member requests that a copy of OUR reports be sent to another agency and/or person. A form must be completed for each individual or agency to which the report is to be sent.
An authorization to obtain information form (see A23) gives the clinic permission to request information from another individual and/or agency. This form is sent out with each request for an evaluation. Returned forms indicating another individual and/or agency that have information that will be of benefit when providing services to the client will be processed by the administrative professional and filed in the client’s clinic folder.
Safety of Clients
At no time is any child (client or sibling) to be left unattended, either in a therapy room or in the waiting room. When the client is with a clinician, the clinician is responsible for guarding against any injury or exposure to hazards (e.g., climbing on the furniture, playing with electrical outlets, running in the hallways, etc.).
When meeting a client for a therapy session, the student should go to the waiting area and escort the client to the therapy room. At the conclusion of the session, the clinician must take young clients back to the waiting area. The clinician is to be certain a parent or responsible adult is waiting for the client before leaving the area.
Medical Emergency
If anyone in the clinic appears to be having a medical emergency (e.g., stroke, seizures, heart failure):

Ease the person to the floor and take precautions to prevent injury by moving them away from any object that could fall on them or harm them in any way. Additionally, do not restrain the individual.

Stay with the individual at all times and Call 911.

Do not give the person food or drink
Injury
If a client or clinician injures himself/herself in the clinic or during an off-campus practicum, the student clinician is to report it at once to a supervisor and the administrative professional. Written documentation may be required.
22

Client/Clinician Leaving the Clinic
Students wanting to take their clients outside the Ewing Clinic must obtain permission from their supervisor. For minors (under the age of 18), permission must also be obtained from the parent or guardian before the client is allowed outside with the clinician. The student must inform the administrative professional that the client and clinician are leaving the clinic. The above rules regarding safety of the client apply while you are outside the clinic. Under no circumstances should students or supervisors transport clients in their cars.
If an emergency arises while outside of the clinic follow the same emergency procedure as in the clinic. The clinician must stay with the client until the medical professionals give permission to return to the clinic.
General Emergency Procedures
All students are responsible for the knowledge of the following emergency procedures:
Clearing the Clinical Area
All persons in the Speech and Hearing Clinic are to leave the building using the exit through the main lobby. All clinical people should remain in the same general area outside, approximately 200 feet from the building.
Student clinicians are to stay with their clients at all times. Students are responsible for helping their clients to vacate the clinical area in a timely manner.
The administrative professional is responsible for directing people in the waiting area to leave the building through the lobby exit.
Clinical supervisors who are present in the clinic will assist in monitoring the orderly clearing of the clinical area.
Accounting for Full Clearance of the Clinical and Waiting Areas
The administrative professional will be responsible for determining if all people in the waiting and clinical areas have left the building. To do this, she will take with her, when leaving the building, the therapy and diagnostic schedules.
In the event of a real emergency, the administrative professional will report to the
Command Post established by the Fire Department with the names of individuals unaccounted for.
Doors, Windows, Lights
Doors of rooms being vacated are to be closed but unlocked. Windows are to be closed with the curtain open. Lights are to be left on.
23

Drill vs. “Real” Alarm
The administrative professional is typically notified by Security of any scheduled fire drills.
Blocked Exit
Should the Lobby exit be unusable, the exit next to room 214 will be used as the alternative route out of the Speech and Hearing Clinic.
Knowledge of an individual’s health status (including HIV, AIDS, and hepatitis) is confidential. Therefore, students/supervisors will not be aware of potential health risks posed by client contact. The use of universal precautions is mandatory.
Gloves
All clinicians and supervisors will use protective gloves to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient is anticipated.
There are 3 distinct reasons for wearing gloves:

They reduce the possibility that personnel will become infected with microorganisms infecting the patient.

They reduce the likelihood that personnel will transmit their own endogenous microbial flora to patients.

They reduce the possibility that personnel will become transiently colonized with microorganisms that can be transmitted to other patients.
Gloves are worn for touching blood and body fluids, mucous membranes, or nonintact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures such as drawing blood or manipulating stopcocks on arterial lines. Gloves are changed after contact with each patient and are removed before leaving the patient’s room.
Wearing gloves does not eliminate the need for hand washing. Hands are washed between patients and immediately upon contact with blood or body fluids.
Remember: gloved hands may contaminate doorknobs, phones or other objects usually touched by other non- protected hands.
Glove Technique

Remove gloves by grasping edge of cuff and pull inside out over hands

Discard into trash receptacle in room

Wash hands or use foam as appropriate
24

Hand Washing
HANDWASHING IS THE SINGLE MOST IMPORTANT MEANS OF
PREVENTING THE SPREAD OF INFECTION.
The principle of hand washing is primarily that of mechanical removal of dirt and microorganisms by the use of an anti-microbial soap for sudsing and friction and flushing with water flowing from wrists to fingertips. Hands are dried with a paper towel from a dispenser – not from a stack as dripping water may contaminate all of the towels. Faucets should be turned off with a clear paper towel.
Clinicians should ALWAYS wash their hands, even when gloves are used. Hands and other skin surfaces are washed immediately and thoroughly if contaminated with blood or other body fluids. Alcohol based foam is adequate as a hand washing substitute if contamination with blood or body fluids has not occurred.
25

26

The information below should be completed by the student clinician.
Student Name:
Client/Site:
Date of Absence:
Reason for Absence:
Clock Hours
Missed:
Proposed Make Up
Plan:
_____________________________
Clinical Director
_________________
Date Received
________________________________________________________________________
The information below should be completed by the Clinic Director
Actual Make Up Plan:
A1
27

Ewing Speech and Hearing Clinic
Ithaca College
Ithaca, NY
As a student, faculty member, employee, visitor, volunteer, or affiliate at the Ewing
Speech and Hearing Clinic at Ithaca College, I understand that I may have access to personal and private information regarding the clients we serve.
I understand such information is strictly confidential, and that whether I become aware of it through a client’s medical record or through conversation, it is privileged information that may not be released to anyone, including family members, without written consent.
I also acknowledge it is my responsibility to prevent the inadvertent disclosure of confidential information in all forms (spoken, printed, and electronic), within and outside of the Ewing Speech and Hearing Clinic. It is my obligation to protect client’s privileged information even after my association with the clinic is terminated.
I agree to only access information that is necessary to complete my legitimate duties as defined by my relationship to the Ewing Speech and Hearing Clinic (student, faculty member, employee, visitor, volunteer, or affiliate).
I understand that maintaining client confidentiality is a condition of my continued affiliation with the Ewing Speech and Hearing Clinic. Any breech of this agreement, or reasonable suspicion thereof, may lead to disciplinary and legal action.
__________________________________________________________________
Name (please print)
__________________________________________________________________
Signature (Date)
Affiliation:
Student
Faculty member
Employee
Visitor
Volunteer
Other__________________
A2
28

PERMISSION FOR FOOD
I give my permission for my child _____________________________ to have food as part of therapy in the Ewing Speech and Hearing
Clinic.
My child has the following food allergies:
___________________________________________________________________
_____________________________________________
I prefer that my child NOT have the following foods:
___________________________________________________________________
_____________________________________________
__________________________________ __________________
Date Signature of parent/guardian
A3
29

Student: ______________________ Clinical Supervisor: ___________________
Clinic Course: UG G1 G2 G3 G4
________________________________________________________________________
Skill or Knowledge area of concern:
Description of how problem was demonstrated:
Remedial Action Plan (goals and procedures):
To be completed by: ____________________
Date
Consequence if not completed:
Date Initiated: ____________________ Student Signature: ___________________________________
Faculty Signature: __________________________________
Clinic Director Signature: ____________________________
______________________________________________________________________________________
Plan completed: __________________________ ________________________
Student Date
__________________________ ________________________
Clinical Supervisor Signature Date
__________________________ ________________________
Clinic Director Date
A4
Revised 01/13
30

Client Rights at the Sir Alexander Ewing Ithaca College Speech and Hearing Clinic

To receive considerate, professional and respectful care.

To participate voluntarily in and consent to services provided.

To be informed of the names of the clinician and supervisor who will be involved in your care.

To obtain information regarding fees for service and an explanation of all charges.

To privacy and confidentiality of all information and records regarding care and that access to information will be limited to those involved in the therapeutic process.

To receive clinically appropriate care and treatment.

To have adequate time to ask questions and receive feedback.

To access and review your clinical record and have the information explained.

To express suggestions, concerns, and grievances in an appropriate manner without fear of reprisals of the care or services you are receiving.

To refuse or terminate services and to be told of the potential clinical implications of such a decision.

To receive services without discrimination as to ones age, race, disability, handicap, religious beliefs, gender, national origin, and/or sexual orientation.

To appropriate referrals.
A5
31

Client and Family Responsibilities and Participation at the Sir Alexander Ewing
Ithaca College Speech and Hearing Clinic
The services that you receive are partially dependent upon you acting in a cooperative manner with the student clinicians, faculty and staff at Ithaca College. You are encouraged and relied upon to maintain certain responsibilities while receiving services at the Sir Alexander Ewing Speech and Hearing clinic.

You have the responsibility to provide accurate and complete medical history, and other information related to your Speech-Language or Hearing impairment.

You have the responsibility to ask questions if you do not understand the treatment plan and/or course of treatment developed by your clinician.

You have the responsibility to arrive on time as scheduled for appointments and to notify the Speech and Hearing clinic in advance in case of canceled appointments and delays. Clients who have three unexcused absences will be dismissed from therapy.

You have the responsibility for treating the student clinicians, faculty and staff in a respectful manner.

You have the responsibility to pay any charges billed to you.

You have the responsibility to supervise children and comply with the Ewing
Clinic waiting room rules.
A6
32

LOG SHEET OF CLOCK HOURS
Student Clinician: Supervisor:
Client Initials/Placement: Sem. & Yr:
Disorder (Indicate the number of hours per disorder)
Articulation
Voice
[ ]
[ ]
Language
AAC/ATC
[ ]
[ ]
Fluency [ ]
Cognition [ ]
Hearing [ ] Swallowing [ ] Soc. Aspects [ ]
Age Group: Birth-K [ ]
Grades 7-12 [ ]
Grades 1-6 [ ]
Adult [ ]
Date
________________
Supervisor's Signature
Work Done (Summary)
Grades 5-9 [ ]
DX
Subtotals:
Total Number of Hours:
Clock Hours
TX
______________
ASHA ID #
Rev. 2014
A8
33

SIR ALEXANDER EWING-ITHACA COLLEGE SPEECH AND HEARING CLINIC
Ithaca College, Ithaca, NY 14850
EVALUATION CONSENT FORM
I hereby consent to evaluation of my speech/hearing condition by personnel of the Sir Alexander
EwingIthaca College Speech and Hearing Clinic (hereinafter “Clinic”). I have been fully informed of the risks and possible consequences involved in the evaluation of a speech/hearing condition by __________________________________, a student or an employee of Ithaca College, and agree to hold Ithaca College, its agents and employees, harmless from any claims, liability, loss or expense arising from any injury or complication which may result from such evaluation.
I also agree to permit the presence of observers for educational purposes while I am undergoing evaluation at the Clinic.
Further, I agree to permit the taking of pictures and/or audio/video recordings of any speech/hearing evaluation session at the Clinic, subject to the condition that I will not be identified by name in any picture or recording. I understand that the pictures and/or audio/video recordings will be made available for viewing by faculty, students and personnel of Ithaca College for educational purposes or for promotion of the services and educational facilities of the Clinic and the Ithaca College Department of Speech Pathology and Audiology.
I understand that my consent may be revoked at any time and that the evaluation will be discontinued immediately.
Name of Client: ___________________________________________________________
Signature of Client: ________________________________________________________
(if 18 years of age or older)
Date: _____________________________________
I hereby certify that I am the parent/legal guardian of the minor child whose name is listed above.
On behalf of that child/ward, I hereby consent to all the terms and conditions included in this form.
Name of Parent/Guardian: __________________________________________________
Signature of Parent/Guardian: _______________________________________________
Date: ____________________________________
A9
34

EWING-COLLEGE SPEECH AND HEARING CLINIC
953 Danby Road, Ithaca College, Ithaca, New York 14850
RELEASE OF CONFIDENTIAL INFORMATION FROM THE EWING SPEECH
AND HEARING CLINIC
Patient Name Date of Birth
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:
1.
This authorization will allow the Ewing Speech and Hearing Clinic to send written/electronic/verbal information to the person or agency below.
2.
I have the right to revoke this authorization at any time by writing to the Ewing Speech and
Hearing Clinic. I understand that I may revoke this authorization except to the extent that action has already been taken on this authorization.
3.
Signing this authorization is voluntary.
Name and Address of Provider or Entity to Receive this Information:
Unless Previously revoked by me the specific information below may be disclosed until one year from signature date.
Expiration
Date or Event
Check Items to be Released:
[ ] Speech-language Evaluation and treatment records
[ ] All records – last 3 years
[ ] All records – last 1 year
[ ] Hearing Evaluation and Treatment records
[ ] All records – last 3 years
[ ] All records – last 1 year
If not the client, name of person signing form: Authority to sign on behalf of client:
All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.
___________________________________________________ ________________________
Signature of Client or Representative Authorized by LAW Date
A10
11/2102
35

SPEECH EVALUATION CHARGE / FOLLOW-UP
Client_________________________ Evaluation Date_______________
Screening ( ) Initial Evaluation ( ) Re-Evaluation ( )
Clinician________________________________
Supervisor_______________________________
TX is not recommended____ Outside referral to___________________
TX is recommended ____ Duration/Frequency of TX______________
Disorder Type______________________________________________
Form Completed by___________________________
Date________________________
36

A11
SIR ALEXANDER EWING SPEECH AND HEARING CLINIC
Ithaca College, Ithaca, NY 14850
THERAPY SCHEDULE REQUEST
Client’s Name ___________________________ Date ________________
Phone _______________________
Please indicate with an “X” the times you are available for therapy sessions or a speech/language diagnostic evaluation. Because of our need to be flexible and meet each client’s needs, please indicate a minimum of five available time slots.
The speech clinic is open 9:00-5:00 Monday through Thursday.
Monday Tuesday Wednesday Thursday Friday
9:00-10:00
10:00-11:00
11:00-12:00
12:00-1:00
1:00-2:00
2:00-3:00
3:00-4:00
4:00-5:00
The completion of this form does not necessarily ensure you of a definite placement in our program for t he next semester. The form is a way of assisting us in compiling the semester’s therapy schedule. 12/07
37

A12
Sir Alexander Ewing-Ithaca College Speech and Hearing Clinic
Ithaca College, Ithaca, New York 14850
Diagnostic Report
*All of the below information should be omitted with the exception of the supervisor’s name, the clinician’s name, the date of the plan, the diagnosis, and the
ICD 10 and CPT codes (available from Julie Chambers).*
N
AME
:
A
P
DDRESS
HONE :
:
P
ARENTS
:
$
$
$
$
D
D
A
ATE OF
ATE OF
GE :
E
B
VALUATION
IRTH
R EFERRED B Y :
: $
$
$
: $
C LINICIAN : $
S
UPERVISOR
: $
S PEECH
ICD 10
/L
C
ANGUAGE
ODE
:
D IAGNOSIS :
R EFERRAL AND C OMPLAINT
$
B ACKGROUND H ISTORY (M EDICAL , SOCIAL , EDUCATIONAL , EMPLOYMENT , FAMILY ,
DEVELOPMENTAL , AND SPEECH AND LANGUAGE )
$
R ESULTS OF T ESTING ( SECTION HEADINGS MAY VARY , INCLUDE OBJECTIVE DATA AND CLINICAL
IMPRESSIONS )
$
E DUCATION P ROVIDED ( IF APPROPRIATE )
$
D IAGNOSTIC S UMMARY
$
38

P ROGNOSIS
$
R ECOMMENDATIONS
1. $
2. $
3. $
(Name, credentials; position as desired by the
Individual supervisor) cc: $
A13
(Name, Credentials)
Graduate Clinician
39

How to insert phonetic symbols in WORD documents
1) Go to the insert heading on the top of the toolbar.
2) Click on Symbol .
3) Change the font in the Symbol screen to Lucida Sans Unicode.
4) Change the subset tab to IPA Extensions .
5) The following sounds cannot be found in IPA Extensions , and must be found in the following subset categories:
Latin - 1
(æ, ð)
Latin Extended-A
(ŋ)
Latin Extended-B (O)
6) Click on the desired symbol.
7) Click on insert . (The symbol will not appear in the document unless you click insert).
The following consonants and vowels requiring special symbols can be found using
Lucida Sans Unicode and the IPA Extensions subset:
/ ʧ
/, / ʤ
/, / ʒ /, /ŋ/, / ʃ /, /O/, /ð/
/ ɑ
/, / ɛ
/, / ɪ
/, /e ɪ /, /æ/, / ʊ
/, / ʌ /, /ə/, / ɔ
/, /a ʊ
/, /a ɪ
/, / ɔɪ
/, / ɚ
/, / ɝ
/
** It is necessary to have Microsoft Word to find these symbols using the aforementioned process. If using Microsoft Works, you can copy and paste these symbols into the document being prepared by copying them from another document.
A14
40

2014 Standards
Student: _______________________ Location: _________________________
Supervisor: ____________________ Date of DX: _______________________
Clinic Course: G1 G2 G3 G4
Client Info: (check all that apply):
Age Group: __Early Childhood (Birth-grade 2) __Childhood (grades 1-6)
__Middle Childhood (grades 5-9) __ Adolescence (grades 9-12) __Adult
Disorder Types/Areas Addressed: __ Articulation __Fluency __Voice/resonance ___Hearing
__Rec/Exp Language __Cognitive Aspects Communication __AAC/AT __Swallowing __Culturally Diverse
__Social Aspects Communication __Aural Rehab __High Risk Population (specify)____________
Knowledge and Skills
The student effectively:
Exceed expectations
Meets expectations
Approaching expectations
Un- satisfactory
N
/
A
Comments
Demonstrated knowledge of communication/swallowing disorder/difference. (IV-C)
Demonstrated current knowledge in the principles of
Prevention and assessment. (IV-D)
Conducted screening and prevention procedures appropriate to the assignment. (V-B 1.a)
Collected case history information and integrated information from client, family, caregivers, teachers and relevant others. (V-B 1.b)
Selected and administered appropriate evaluation procedures (V-B 1.c)
 Behavioral observations

Non-standardized tests

Standardized tests

Instrumental procedures
Adapted evaluation procedures to meet the client needs.
(V-B 1.d)
Prepared diagnostic setting to meet client needs:
Created a safe, healthy, dynamic, and motivational environment for the client (TSSLD)
Interpreted, integrated and synthesized all information to develop diagnoses and made appropriate recommendations for intervention (V-B 1.e)
Completed administrative and reporting functions necessary to support evaluation (V-B 1.f)

Report contained pertinent, accurate and complete information

Report used correct grammar, punctuation, and spelling

Report logically organized, avoided excessive use of professional jargon
Referred clients for services as appropriate (V-B 1.g)
Communicated effectively, recognized the needs, values

and preferred mode of communication and cultural/linguistic background of the client, caregivers and relevant others (V-B 3.a)
Knowledge and Skills
The student effectively:
Exceeds expectations
Meets expectations
Approaching expectations
Un- satisfactory
N
/
A
Comments
Effectively utilized technology (TSSLD)
Provided counseling regarding communication disorders to clients, caregivers and relevant others (V-B 3.c)
Demonstrated knowledge of standards of ethical conduct.
(IV-E)
Displayed appropriate professional skills

Dependable/punctual/ met deadlines

Professional manner and dress/attitude/respect

Adheres to attendance and cancellation policy

Appropriate Level of Engagement and independence(relative to Others with a similar
 level of experience
Overall:
_____ Exceeds expectations
_____ Meets expectations
_____ Approaching expectations
_____ Unsatisfactory
Comments (Strengths, Weaknesses):
Grade: _________
(College faculty are responsible for determining student grades. For students placed off campus, please recommend a grade)
________________________________ ______________________________
Clinical Supervisor Student
Revised with ASHA 2014 standards 06/2014 mp
A15

REQUEST FOR CLIENT FILE
Client: ____________________________________ Date: ______________________
Person requesting file: ______________________ Time Out: __________________
Supervisor: _______________________________
Purpose of request: _____________________________________________________
A16

2014 Standards
Student: _______________________ Location: _________________________
Supervisor: ____________________ Semester / Date: ___________________
Midterm or Final (circle one) Number of Sessions: _________________
Clinic Course: UG G1 G2 G3 G4
Client Info: (check all that apply):
Age Group: __Early Childhood (Birth-grade 2) __Childhood (grades 1-6)
__Middle Childhood (grades 5-9) __ Adolescence (grades 9-12) __Adult
Disorder Types/Areas Addressed: __ Articulation __Fluency __Voice/resonance ___Hearing
__Rec/Exp Language __Cognitive Aspects Communication __AAC/AT __Swallowing __Culturally Diverse
__Social Aspects Communication __Aural Rehab __High Risk Population (specify)____________
Knowledge and Skills
The student effectively:
Exceeds expectations
Meets expectations
Approaching expectations
Un- satisfactory
N
/
A
Comments
Demonstrated the ability to integrate information
pertaining to normal and abnormal human
development across the lifespan. (ASHA IV-B)
Demonstrated knowledge of communication/swallowing disorder/difference. (IV-C)
Demonstrated current knowledge in the principles of
Intervention. (IV-D)
Demonstrated knowledge the integration of research
principles into evidence-based clinical practice. ( IV-F)
Created a safe, healthy, dynamic, and motivational learning environment for the client. (TSSLD)
Developed appropriate intervention plan with measurable and achievable goals that meet the clients’ needs. (V-B 2.a)
Implemented intervention plans and involved clients and relevant others in the planning process (V-B 2a.) intervention process (V-B 2.b) and case management (V-B
3.b)
Selected or developed, and used appropriate techniques, materials & instrumentation for prevention and intervention. (V-B 2.C)
Measured and evaluated client’s performance and progress. (V-B 2.d)
[ie: baseline testing, extension testing, post testing, etc]



Modified intervention plans, strategies, materials, or instrumentation as appropriate to meet the needs of the client. (V-B 2.e)
Knowledge and Skills Exceeds expectations
Meets expectations
Approaching expectations
Un- satisfactory
N
/
Comments

The student effectively:
Completed administrative and reporting functions necessary to support intervention. (V-B 2.f) [Reports contained pertinent, accurate and complete information; used correct grammar, punctuation and spelling; were logically organized, avoided excessive use of jargon]

Treatment Plan

Lesson Plan

SOAP Notes

Progress Report
 Other (family letters, referral letters etc.)
Communicated effectively, recognized the needs, values and preferred mode of communication and cultural/linguistic background of the client, caregivers and relevant others. (V-B 3.a)
A
Effectively utilized technology to enhance client learning.
(TSSLD)
Provided counseling regarding communication disorders to clients, caregivers and relevant others. (V-B 3.c)
Demonstrated knowledge of standards of ethical conduct.
(IV-E)
Displayed appropriate professional skills

Dependable/punctual/ meets deadlines
 Professional manner and dress/attitude/respect

Applied feedback /initiated solutions

Appropriate Level of Engagement and independence

Followed attendance and cancellation policies
Comments (Strengths, Weaknesses):
Recommended Grade: _________
(College is responsible for determining final grades. Supervisors of students placed off campus: please recommend a grade.)
________________________________ ______________________________
Clinical Supervisor Student
Revised with ASHA 2014 standards 06/2014 mp
A17

Sir Alexander Ewing-Ithaca College Speech and Hearing Clinic
Ithaca College, Ithaca, New York 14850
Treatment Plan
*All of the below information should be omitted with the exception of the supervisor’s name, the clinician’s name, the date of the plan, the diagnosis, and the ICD 10 and CPT codes (available from
Julie Chambers).*
N
AME
: D
ATE OF
P
LAN
:
(Initial Submission Date)
A DDRESS : D ATE OF B IRTH :
P HONE :
P ARENTS :
S
UPERVISOR
:
C LINICIAN :
A GE :
D IAGNOSIS :
ICD 10 C
ODE
:
CPT C ODE :
S TATEMENT OF THE P ROBLEM
S UMMARY OF T HERAPY H ISTORY
CURRENT LEVEL OF PERFORMANCE (Standardized or baseline testing results)
T HERAPY G OALS AND R ATIONALES
Long-Term Goals
(Optional based on nature of disorder)

Short-Term Objectives (Semester Length)
1.
2.
3.
4.
Rationale
$
Student Clinician
$
Signature of Patient or Guardian
(Parent or guardian if client is under 18)
$
Clinical Supervisor
Date

A18
Clinical Practicum Hours/Experiences
Student:
Semester:
Evaluation
Artic/Phonology
Rec/Exp Language
Voice
Fluency
Cog Communication
ComModalities/AAC
Swallowing
Social Aspects
Hrs
Obtained
Treatment
Artic/Phonology
Rec/Exp Language
Voice
Fluency
Cog Communication
Com Modalities/AAC
Swallowing
Social Aspects
Audiology
Eval/Screening
Aural Rehab
Supervisor/
ASHA ID# Location
Age Groups
(see below)
Hours Per
Age Group
Of above, specify hours that involved:
Prevention
CLD
Age Groups: EC (Birth-grade 2) Ch (grades 1-6) MC (grades 5-9)
Ad (grades 7-12) At (Adult)
Clinical Director Use Only
_______________________________________
Mary Pitti, MS, CCC-SLP
Total Number of Hours: _______ Clinical Director
ASHA # 01073480
A19

SIR ALEXANDER EWING-ITHACA COLLEGE SPEECH AND HEARING CLINIC
ITHACA COLLEGE, ITHACA, New York 14850
THERAPY ATTENDANCE RECORD
Month of_______________
Client Name_____________________________________
Clinician(s) _____________________________________
Fill in date of each therapy session scheduled and check either “Cancellation” or “Attended” (1/2 hour, 1 hour, 2 hours).
Date of Therapy Cancellation
Attended
½ Hour 1 Hour
2 Hour
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Total Number of Sessions Attended ______

A20
SIR ALEXANDER EWING-ITHACA COLLEGE SPEECH AND HEARING CLINIC
ITHACA COLLEGE, ITHACA, NY 14850
TELEPHONE-CONSULTATION LOG SHEET
Re: Client______________________________________________
Date _____________
Name of Person called _____________________________________________________
Phone ____________________________________
Contact/Message:
Name of Person Making the Call ____________________________________________
Date _____________
Name of Person called _____________________________________________________
Phone ____________________________________
Contact/Message:
Name of Person Making the Call ____________________________________________

A21
SIR ALEXANDER EWING-ITHACA COLLEGE SPEECH AND HEARING CLINIC
Ithaca College, Ithaca, NY 14850
TREATMENT CONSENT FORM
I hereby consent to treatment of my speech/hearing condition by personnel of the Sir Alexander Ewing-
Ithaca College Speech and Hearing Clinic (hereinafter “Clinic”). I have been fully informed of the risks and possible consequences involved in the treatment of a speech/hearing condition by
__________________________________, a student or an employee of Ithaca College, and agree to hold Ithaca College, its agents and employees, harmless from any claims, liability, loss or expense arising from any injury or complication which may result from such evaluation.
I also agree to permit the presence of observers for educational purposes while I am undergoing treatment at the Clinic.
Further, I agree to permit the taking of pictures and/or audio/video recordings of any speech/hearing treatment session at the Clinic, subject to the condition that I will not be identified by name in any picture or recording. I understand that the pictures and/or audio/video recordings will be made available for viewing by faculty, students and personnel of Ithaca College for educational purposes or for promotion of the services and educational facilities of the Clinic and the Ithaca College Department of
Speech-Language Pathology and Audiology.
I understand that my consent may be revoked at any time and that the treatment will be discontinued immediately.
Name of Client: ___________________________________________________________
Signature of Client: ________________________________________________________
(if 18 years of age or older)
Date: _____________________________________
I hereby certify that I am the parent/legal guardian of the minor child whose name is listed above. On behalf of that child/ward, I hereby consent to all the terms and conditions included in this form.
Name of Parent/Guardian: __________________________________________________
Signature of Parent/Guardian: _______________________________________________
Date: ____________________________________
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SIR ALEXANDER EWING-COLLEGE SPEECH AND HEARING CLINIC
Ithaca College, Ithaca, New York 14850
RELEASE OF CONFIDENTIAL INFORMATION TO THE EWING SPEECH AND
HEARING CLINIC
Patient Name Date of Birth
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:
4.
This authorization will allow the person or entity listed below to send written/electronic/verbal information to the Ewing Speech and Hearing Clinic.
5.
I have the right to revoke this authorization at any time by writing to the Ewing Speech and
Hearing Clinic. I understand that I may revoke this authorization except to the extent that action has already been taken on this authorization.
6.
Signing this authorization is voluntary. I understand that generally my treatment or payment will not be conditional upon my authorization of this disclosure. However, I do understand that
I may be denied treatment in some circumstances if I do not sign this consent.
Name and Address of Provider or Entity to Release this Information:
Unless Previously revoked by me the specific information below may be disclosed until one year from signature date.
Expiration Date or Event
Check Items to be Released:
[ ] Speech-language evaluation and treatment records
[ ] All records – last 3 years [ ] All records – last 1 year
[ ] Hearing evaluation and treatment records
[ ] All records – last 3 years [ ] All records – last 1 year
[ ] Psychological/Social assessments
[ ] All records – last 3 years [ ] All records – last 1 year
[ ] Educational assessments
[ ] All records – last 3 years [ ] All records – last 1 year
[ ] Medical records
Details: ________________________________________________________
[ ] Other: ________________________________________________________
If not the client, name of person signing form: Authority to sign on behalf of client:
All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.
___________________________________________________________ _________________________
Signature of Client or Representative Authorized by LAW Date

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11/2012
SIR ALEXANDER EWING – ITHACA COLLEGE SPEECH AND HEARING CLINIC
Ithaca College, Ithaca, NY 14850
DAILY MATERIALS SIGN-OUT SHEET
Name of Time Std Worker Material Time Std Worker
Date Borrower Taken Signing Out Taken Retd Signing In

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S IR A LEXANDER E WING -I THACA C OLLEGE S PEECH AND H EARING C LINIC
S MIDDY H ALL , I THACA C OLLEGE , I THACA , N EW Y ORK 14850
P ERMISSION TO S IGN O UT M ATERIALS O VERNIGHT /W EEKENDS
Student Name: ___________________________________ Date: __________________
Email Address: ________________________ Cell phone number:___________________
Item(s): _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Overnight _________
Weekend __________
(check one)
Faculty Signature: ________________________________________________________

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Sir Alexander Ewing-Ithaca College Speech and Hearing Clinic
Ithaca College, Ithaca, New York 14850
Progress Report
*All of the below information should be omitted with the exception of the supervisor’s name, the clinician’s name, the date of the plan, the diagnosis, and the ICD 10 and CPT codes (available from Julie Chambers).*
N
AME
: D
ATE OF
R
EPORT
:
D ATE OF B IRTH : A DDRESS :
P HONE :
P ARENTS :
S UPERVISOR :
C LINICIAN :
A
D
GE :
IAGNOSIS :
ICD 10 C ODE :
CPT C ODE :
S ESSIONS A VAILABLE : S ESSIONS A TTENDED :
D ISPOSITION
Include a statement like the client will/will not be returning to the Ewing Clinic for the ______ semester.
S TATEMENT OF THE P ROBLEM
O BJECTIVES
P RESENT S TATUS
This section typically includes the following items (check with your supervisor):

State if goal was met, exceeded, not met

Compare baseline to current level of performance

Discuss consistency in ability to achieve the goal over several sessions and the cues needed


Identify what they were unable to do, or discuss limitations that prevented them from reaching this goal
C LINICAL I MPRESSIONS
R ECOMMENDATIONS
Student Clinician
Signature of Client or Guardian
(Parent or guardian if client is under 18) cc: parents
Clinical Supervisor
Date

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LOG SHEET OF THERAPY OBSERVATIONS
Student Clinician: Be sure to COMPLETE after each therapy session since this becomes an official record.
Student Clinician: Location:
Date Description of Session(s) Observed Hours
Total Number of Observation Hours:

__________________
Supervisor's Signature
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_________________
ASHA ID #