The University of Melbourne
Audiology Student Clinical Placement Assessment Form
THIS ASSESSMENT FORM IS FOR STUDENT PERSONAL FEEDBACK
AND INTERNAL UNIVERSITY PURPOSES ONLY. IT IS NOT TO BE COPIED AND
SENT ON TO OTHER PEOPLE INCLUDING PROSPECTIVE EMPLOYERS.
Date/s of placement:
Brief description of caseload including hearing loss (degree, type and configuration) and degree
of difficulty to test (e.g. over or under responder, non-English speaking background, difficult
For the areas of professional conduct, interpersonal interactions, clinical assessment skills
and amplification, please comment on the student’s strengths and weaknesses.
1. The examples given for each of the areas are not exhaustive and/or may not apply in all
2. Consider the student’s experience/knowledge level at this stage of the course in making
3. If completing the form electronically please delete extra lines in each section as required.
E.g.: Punctual, notifies supervisor if unable to attend placement, keeps files in order and up to date,
interacts in a professional manner with supervisor, other members of health care team, and support
staff, shows interest in the field of Audiology, shows interest in present clinical placement, takes
initiative to try new procedures, works independently when appropriate, seeks supervision when
appropriate, responds appropriately and promptly to feedback – interprets and follows instructions.
E.g.: Establishes rapport with patients and families, adjusts level of language and presentation style
to accommodate patient’s communication abilities, shows interest and sympathetic understanding to
patient and caregivers, puts concerns of patients ahead of their own, and uses an interviewing style
which is effective in conveying information and acknowledging emotional needs.
Clinical Assessment Skills
E.g.: ability to perform pure tone testing, masking, speech recognition testing, speech masking and
other testing, ability to resolve test inconsistencies, interpretation of results and implications for
management, testing completed in a reasonable amount of time.
E.g.: Audiological and non-audiological considerations in pre-selection, selection of appropriate
amplification features/styles, selection of appropriate earmould/ear tip characteristics, impression-
taking, electro acoustic analysis (test box measures), real ear measurements (probe tube
measures), use of prescriptive formula (e.g. NAL-NL1) and NOAH software, use of manufacturer’s
software to adjust amplification/features/options (at fitting/review appts), evaluation of MPO, trouble
shooting hearing aid problems (e.g. aid not working, feedback, etc), counselling on care,
maintenance, and adjustment to hearing aid, outcome assessment, assistive listening devices
selection and counselling
Please email the completed form to firstname.lastname@example.org or mail to Audiology, Hearing and
Speech Sciences Building, 550 Swanston Street, The University of Melbourne, 3010.