STUDENT EVALUATION FORM
Intervention
Student: _______________________
Supervisor: ____________________
Midterm or Final (select one)
Location: _________________________
Semester / Date: ___________________
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
Demonstrated the ability to integrate information
pertaining to normal and abnormal human
development across the lifespan. (ASHA IV-B)
Demonstrated knowledge of
communication/swallowing disorders/differences. (IV-C)
Demonstrated current of 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 met 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 and instrumentation for prevention and
intervention. (V-B 2.C)
Measured and evaluated client’s performance and
progress. (V-B 2.d)
[e.g., 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)
Revised with ASHA 2014 standards and Teacher Education Professional Dispositions 03/2016 mp
Unsatisfactory
N
/
A
Comments
Exceeds
expectations
Knowledge and Skills
The student effectively:
Meets
expectations
Approaching
expectations
Unsatisfactory
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)
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)
Professional Dispositions (refer to page 3)
I. Professional Responsibility (1-4)
II. Collaboration and Communication (1-5)
III. Reflective Practice and Professional Development (1-5)
Comments (Strengths, Limitations):
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 and Teacher Education Professional Dispositions 03/2016 mp
N
/
A
Comments