Hours Form

							                                     CLINICAL PRACTICE HOURS IN SPEECH-LANGUAGE PATHOLOGY
Name:                                        Dates:                                                      Practicum Site:

                                   ASSESSMENT/                          TREATMENT/
                                  IDENTIFICATION                        MANAGEMENT
                                                                                                          Clinical/Prof.        Sub Total                        Min. Req.
                           Client Specific   Client Related    Client Specific          Client Related     Activiites            Hours           Total All Age    Hours
LANGUAGE              C                                                                                                                      0
                                                                                                                                                      0             40
Developmental         A                                                                                                                      0
                      C                                                                                                                      0
LANGUAGE/ Acquired                                                                                                                                    0             30
                      A                                                                                                                      0
                      C                                                                                                                      0
DYSPHAGIA                                                                                                                                             0             10
                      A                                                                                                                      0
ARTICULATION/         C                                                                                                                      0
                                                                                                                                                      0             20
PHONOLOGY             A                                                                                                                      0
                      C                                                                                                                      0
MOTOR SPEECH                                                                                                                                          0             10
                      A                                                                                                                      0
                      C                                                                                                                      0
FLUENCY                                                                                                                                               0             15
                      A                                                                                                                      0
                      C                                                                                                                      0
VOICE/RESONANCE                                                                                                                                       0             15
                      A                                                                                                                      0
                      C                                                                                                                      0
OTHER                                                                                                                                                 0
                      A                                                                                                                      0
                      C                                                                                                                      0
AUDIOLOGY - minor                                                                                                                                     0             20
                      A                                                                                                                      0
                      Ax min. reqd: 20hrs                     Tx: min. reqd: 20 hrs.
TOTAL HOURS        C                 0                    0              0                           0                     0                 0                      50
TOTAL HOURS        A                 0                    0              0                           0                     0                 0                      50
TOTAL CLIENT HOURS        Ax HOURS/ Min: 100                  Tx HOURS/ Min: 100                         Max: 50 hrs.
                                                                                                                               Grand Total            0            350
                                    0                                     0                                                0

Signature (Student)                                                                    Signature (Clinical Supervisor)