SLP Name:_________________________
School District: ______________________
Date of Artifact Submission: ____/_____/____
Artifact Submission Form
Evaluator:__________________________
School: ____________________________
Grade Level(s):______________________
Identify the domain and standard addressed by the attached artifact. Please submit one artifact form per domain. Check all artifacts under the appropriate domain that you are submitting or will have available to review in your room.
Domain I: Planning
Example of objectives taught for articulation, language, voice, and/or fluency
Articulation
Language
Voice
Fluency
Domain II: Assessment
Sample Caseload Files
Evidence in the caseload files provide the following assessment evidence:
Multidisciplinary Evaluation Report (MDE)
Standard Assessment protocols
Other assessment Data
Domain III: Instruction
Observation
Student data sheets/daily student data
Student homework/class folders
Domain IV: Learning Environment
Observation
Domain V: Professional Responsibilities
Sample Caseload Files
Evidence in the caseload files provide the following evidence of professional responsibilities
Individualized Education Plan
Parent Permission documentation
Referral to Placement documentation
Dismissal Documentation
Other evidence of professional responsibilities
Copy of schedule (including revised schedules throughout the year)
Copy of student progress report
Professional growth documentation
Documentation of providing guidance and leadership to school staff and parents through presentations, materials/resources, collaboration and participating in school initiatives