CAA Accreditation Application
Speech Language Pathology Clinical Site Data Collection Worksheet
Instructions:
 Use this worksheet to collect data about each clinical education site used by the accredited
graduate program for the most recently completed academic year.
 Include any on-campus facilities.
Clinical Site Name:
Type of facility (select one):
Hospital
School
Industry
Government agency
Private practice
College/university
Residential healthcare facility
Research/science/lab
Other
Specify:
This facility is contracted to support which mode of instructional delivery? (Select all that apply.)
Residential only
Distance education only
Satellite only
Combined residential and other modality of delivery
NOTE: Select “combined residential and other modality of delivery” when courses are offered
simultaneously in a residential classroom and to a satellite campus via distance education technology.
Indicate the distance of this site from the program.
1-10 miles
11-20 miles
21-30 miles
31-40 miles
41-50 miles
More than 50 miles
Specify:
CAA Accreditation Application
SLP Clinical Site Data Collection Form
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List the academic and clinical prerequisites required for student placement in this facility.
Note: Your response must not exceed 5000 characters. Please complete a word count on your response
to ensure this limit is not exceeded.
Indicate the typical number of students per supervisor per term:
Number of terms your program has used this facility in the past 2 years:
List the types of activities in which students typically engage.
Note: Your response must not exceed 5000 characters. Please complete a word count on your response
to ensure this limit is not exceeded.
Is a written contract or agreement on file?
Yes
No
What is the age range for adults?
What is the age range for children?
List the culturally and linguistically diverse populations served.
Note: Your response must not exceed 250 characters. Please complete a word count on your response to
ensure this limit is not exceeded.
Indicate the method for reporting clinical population data (Enter “0” if none):
Average number of clients (children and adult) per academic term
Average number of hours spent (children and adult) per academic term
Note:
 The program should select only one method for reporting for all clinical sites.
 Totals will be “system” generated. Please verify.
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SLP Clinical Site Data Collection Form
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Provide clinical population data:
ARTICULATION
Children Adults
Total
Children Adults
Total
Children Adults
Total
Children Adults
Total
Children Adults
Total
Children Adults
Total
Children Adults
Total
Children Adults
Total
Children Adults
Total
Evaluation
Intervention
VOICE & RESONANCE
Evaluation
Intervention
FLUENCY
Evaluation
Intervention
LANGUAGE DISORDERS (Receptive & Expressive)
Evaluation
Intervention
SWALLOWING DISORDERS
Evaluation
Intervention
COGNITIVE ASPECTS OF COMMUNICATION
Evaluation
Intervention
SOCIAL ASPECTS OF COMMUNICATION
Evaluation
Intervention
COMMUNICATION MODALITIES
Evaluation
Intervention
HEARING
Evaluation
Intervention
CAA Accreditation Application
SLP Clinical Site Data Collection Form
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CAA Accreditation Application
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