STUDENT EVALUATION FORM
Diagnostic Assessment
Student: _______________________
Supervisor: ____________________
Location: _________________________
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)____________
Exceed
expectations
Knowledge and Skills
The student effectively:
Meets
expectations
Approaching
expectations
Unsatisfactory
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)
Revised with ASHA 2014 standards and Teacher Education Professional Dispositions 03/11/2016 mp
N
/
A
Comments
Exceeds
expectations
Knowledge and Skills
The student effectively:
Meets
expectations
Approaching
expectations
Unsatisfactory
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)
Professional Dispositions (refer to page 3)
I. Professional Responsibility (1-4)
II. Collaboration and Communication (1-5)
III. Reflective Practice an Professional Development (1-5)
IV. Commitment to Affirming All Students (1-5)
Overall:
_____ Exceeds expectations
_____ Meets expectations
_____ Approaching expectations
_____ Unsatisfactory
Comments (Strengths, Limitations):
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 and Teacher Education Professional Dispositions 03/11/2016 mp