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					  KNOWLEDGE AND SKILLS ACQUISITION (KASA)
             SUMMARY FORM FOR
CERTIFICATION IN SPEECH-LANGUAGE PATHOLOGY




        Knowledge and Skills Acquisition (KASA) Summary Form
           For Certification in Speech-Language Pathology
                               March, 2003
                                     KNOWLEDGE AND SKILLS ACQUISITION (KASA)
                                              SUMMARY FORM FOR
                                         SPEECH-LANGUAGE PATHOLOGY

                                                            Instructions for Use

The Knowledge and Skills Acquisition (KASA) form summarizes a student's acquisition of the knowledge and skills delineated in the Standards for
the Certificate of Clinical Competence (SCCC). Entries are made only upon acquisition of the knowledge or skill; thus the KASA is not an evaluation,
but only a record that a particular knowledge or skill has been acquired.

Required Documentation

1. Students from CAA-accredited programs (Refer to "Automatic Approval" language in Standard I. Degree) must submit the "Verification by
Program Director" page of the KASA when applying for certification.

2. All other applicants must submit the entire, completed document, including the "Verification by Program Director" page when applying for
certification.

Use of the KASA Form


1. The CFCC encourages programs to use the KASA to demonstrate compliance with accreditation standards related to preparing students to meet
ASHA certification requirements. However, programs may develop other documents to verify student's acquisition of knowledge and skills.

2. For students who must submit the entire KASA, and for academic programs wishing to use the KASA as a tracking document, indicate with a
check mark in Column B whether each knowledge and skill was achieved. If a particular knowledge or skill was acquired through work completed in
a specific course or courses, the title and number of the course(s) should be entered in Column C. If the knowledge or skills were acquired in clinical
practicum, enter the title and number of the practicum in Column D. If the knowledge or skill was acquired through course work and/or clinical
practicum, and/or lab or research activities, there should be entries in all of the applicable columns: C, D, and/or E.

3. Students and programs using the KASA are advised to keep a copy in a safe place, should they need to provide information to the Council For
Clinical Certification at a later date (e.g., upon application for reinstatement).

4. CFCC encourages programs and students to periodically review the KASA (or other tracking documents developed by the program) to assist
students in determining knowledge and skills already acquired and those yet to be attained.
                                                                   Knowledge And Skills Acquisition (KASA) Summary Form
                                                                         For Certification in Speech-Language Pathology
Northern Michigan University                            Enter Your Name Here
The KASA form is intended for use by the certification applicant during the graduate program to track the processes by which the knowledge and skills specified in the 2005 Standards for the
CCC are being acquired. Each student should review the KASA form at the beginning of graduate study, and update it at intervals throughout the graduate program and at the conclusion of the
program.

The student, with input and monitoring of program faculty, must enter a check mark in column B as each of the knowledge and skills is acquired. It is expected that many entries will appear in the
course work and the clinical practicum columns, with some entries, as appropriate, in the "Other" (lab, research, etc.) columns. Please enter the course or practicum number and title and
description of other applicable activity.


I. KNOWLEDGE AREAS
                                                                                                                       How Achieved?
                   A                           B                                C                                           D                                               E

                                         Knowledge/
                                          Skill Met?                                                                                                      Other (e.g. labs, research) (Include
               Standards                   (check )                    Course # and Title                    Practicum Experiences # and Title                  description of activity)
Standard III-A. The applicant must
demonstrate knowledge of the
principles of:
    ● Biological sciences                               (Biology Course)
    ● Physical sciences                                 (Physics Course
    ● Mathematics                                       NMU PY Psychological Stat
    ● Social/Behavioral sciences                        (General Psych Course)
Standard III-B. The applicant must
demonstrate knowledge of basic
human communication and
swallowing processes, including
their biological, neurological,
acoustic, psychological,
developmental, and linguistic and
cultural bases
● Basic Human Communication
Processes
                                                        NMU CD 160 Anatomy of Sp & Hearing Mech
                                                        NMU CD 220 Speech and Voice Science
  ● Biological                                          NMU CD 200 Phonetics
                                                        NMU CD 160 Anatomy of Sp & Hearing Mech
  ● Neurological                                        NMU CD 220 Speech and Voice Science




                                                                                                3                                                                               Rev. 1/2010
                                                                                                          How Achieved?
                    A                        B                              C                                  D                                      E

                                         Knowledge/
                                          Skill Met?                                                                                 Other (e.g. labs, research) (Include
               Standards                   (check )                 Course # and Title           Practicum Experiences # and Title         description of activity)

                                                       NMU CD 160 Anatomy of Sp & Hearing Mech
                                                       NMU CD 220 Speech and Voice Science
  ● Acoustic                                           NMU CD 200 Phonetics
  ● Psychological                                      UMD CSD 8235 Counseling Applic
  ● Developmental/Lifespan                             NMU CD 355 Language Development
  ● Linguistic                                         NMU CD 355 Language Development
  ● Cultural
● Swallowing Processes
  ● Biological                                         UMD CSD 5200 Dysphagia
  ● Neurological                                       UMD CSD 5200 Dysphagia
  ● Psychological                                      UMD CSD 5200 Dysphagia
  ● Developmental/Lifespan                             UMD CSD 5200 Dysphagia
  ● Cultural                                           UMD CSD 5200 Dysphagia

Standard III-C. The applicant must
demonstrate knowledge of the
nature of speech, language, hearing,
and communication disorders and
differences and swallowing
disorders, including their etiologies,
characteristics,
anatomical/physiological, acoustic,
psychological, developmental, and
linguistic and cultural correlates.
Specific knowledge must be
demonstrated in the following areas:

Articulation
● Etiologies                                           NMU CD 400 Phonological Disorders
                                                       NMU CD 210 Intro to Voice & Artic
                                                       UMD CSD 8231 Neuro Sp Disor
● Characteristics                                      NMU CD 400 Phonological Disorders
                                                       NMU CD 210 Intro to Voice & Artic
                                                       UMD CSD 8231 Neuro Sp Disor
Fluency
● Etiologies                                           NMU CD 357 Fluency Disorders
                                                       UMD CSD 8205 Adv Fluency Disorders




                                                                                            4                                                             Rev. 1/2010
                                                                                                          How Achieved?
                    A                        B                               C                                 D                                      E

                                         Knowledge/
                                          Skill Met?                                                                                 Other (e.g. labs, research) (Include
             Standards                     (check )                  Course # and Title          Practicum Experiences # and Title         description of activity)
● Characteristics                                      NMU CD 357 Fluency Disorders
                                                       UMD CSD 8205 Adv Fluency Disorders
Voice and resonance, including
respiration and phonation
● Etiologies                                           NMU CD 210 Intro to Voice and Artic
                                                       UMD CSD 8200 Voice Disorders
                                                       UMD CSD 8231 Neuro Sp Disor
● Characteristics
                                                       NMU CD 210 Intro to Voice and Artic
                                                       UMD CSD 8200 Voice Disorders
                                                       UMD CSD 8231 Neuro Sp Disor
Receptive and expressive language
(phonology, morphology, syntax,
semantics, and pragmatics) in
speaking, listening, reading, writing,
and manual modalities
● Etiologies
                                                       NMU CD 356 Language Disorders
                                                       UMD CSD 5230 Assistive Tech
                                                       UMD CSD 5300 Lang Dis Chld, Adol
                                                       UMD CSD 8230 Neuro Lang Disord
● Characteristics
                                                       NMU CD 356 Language Disorders
                                                       UMD CSD 5230 Assistive Tech
                                                       UMD CSD 5300 Lang Dis Chld, Adol
                                                       UMD CSD 8230 Neuro Lang Disord
Hearing, including the impact on
speech and language
● Etiologies                                           NMU CD 351 Audiology
                                                       UMD CSD 5400 Rehab Procedures Hard
                                                       Hearing
● Characteristics                                      NMU CD 351 Audiology
                                                       UMD CSD 5400 Rehab Procedures Hard
                                                       Hearing
Swallowing (oral, pharyngeal,
esophageal, and related functions,
including oral function for feeding;
orofacial myofunction)




                                                                                             5                                                            Rev. 1/2010
                                                                                                     How Achieved?
                    A                      B                             C                                D                                      E

                                       Knowledge/
                                        Skill Met?                                                                              Other (e.g. labs, research) (Include
               Standards                 (check )               Course # and Title          Practicum Experiences # and Title         description of activity)
● Etiologies                                         UMD CSD 5200 Dysphagia
● Characteristics                                    UMD CSD 5200 Dysphagia
Cognitive aspects of communication
(attention, memory, sequencing,
problem-solving, executive
functioning
● Etiologies                                         NMU CD 356 Language Disorders
                                                     UMD CSD 5300 Lang Dis Chld, Adol
                                                     UMD CSD 8230 Neuro Lang Disord
● Characteristics                                    NMU CD 356 Language Disorders
                                                     UMD CSD 5300 Lang Dis Chld, Adol
                                                     UMD CSD 8230 Neuro Lang Disord
Social aspects of communication
(challenging behavior, ineffective
social skills, lack of communication
opportunities)
● Etiologies                                         NMU CD 356 Language Disorders
                                                     UMD CSD 5300 Lang Dis Chld, Adol
                                                     UMD CSD 8230 Neuro Lang Disord
● Characteristics                                    NMU CD 356 Language Disorders
                                                     UMD CSD 5300 Lang Dis Chld, Adol
                                                     UMD CSD 8230 Neuro Lang Disord
Communication modalities
(including oral, manual,
augmentative and alternative
communication techniques, and
assistive technologies)
● Characteristics                                    UMD CSD 5230 Assistive Tech




                                                                                        6                                                            Rev. 1/2010
                                                                                                         How Achieved?
                  A                         B                              C                                  D                                      E

                                        Knowledge/
                                         Skill Met?                                                                                 Other (e.g. labs, research) (Include
               Standards                  (check )                 Course # and Title           Practicum Experiences # and Title         description of activity)
Standard III-D: The applicant must
possess knowledge of the principles
and methods of prevention,
assessment, and intervention for
people with communication and
swallowing disorders, including
consideration of
anatomical/physiological,
psychological, developmental, and
linguistic and cultural correlates of
the disorders.
Articulation

● Prevention                                          NMU CD 400 Phonological Disorders
                                                      NMU CD 210 Intro to Voice & Artic
                                                      NMU CD 400 Phonological Disorders
● Assessment                                          NMU CD 210 Intro to Voice & Artic
                                                      NMU CD 464 Methods of Diagnosis
                                                      NMU CD 400 Phonological Disorders
● Intervention                                        NMU CD 210 Intro to Voice & Artic
                                                      NMU CD 465 Methods of Treatment
Fluency
● Prevention                                          UMD CSD 8205 Adv Fluency Disord

● Assessment                                          NMU CD 464 Methods of Diagnosis
                                                      UMD CSD 8205 Adv Fluency Disord

● Intervention                                        NMU CD 465 Methods of Treatment
                                                      UMD CSD 8205 Adv Fluency Disord
Voice and Resonance

● Prevention                                          NMU CD 160 Anatomy of Sp & Hearing Mech
                                                      UMD CSD 8200 Voice Disorders

● Assessment                                          NMU CD 464 Methods of Diagnosis
                                                      UMD CSD 8200 Voice Disorders

● Intervention                                        NMU CD 465 Methods of Treatment
                                                      UMD CSD 8200 Voice Disorders




                                                                                          7                                                              Rev. 1/2010
                                                                                                      How Achieved?
                  A                      B                             C                                   D                                      E

                                     Knowledge/
                                      Skill Met?                                                                                 Other (e.g. labs, research) (Include
               Standards               (check )                Course # and Title            Practicum Experiences # and Title         description of activity)

Receptive and Expressive Language

                                                   NMU CD 160 Anatomy of Sp & Hearing Mech
● Prevention                                       NMU CD 356 Language Disorders
                                                   UMD CSD 5300 Lang Dis Chld, Adol
                                                   NMU CD 356 Language Disorders
● Assessment                                       NMU CD 464 Methods of Diagnosis
                                                   UMD CSD 5300 Lang Dis Chld, Adol
                                                   UMD CSD 8230 Neuro Lang Disord

                                                   NMU CD 356 Language Disorders
● Intervention                                     NMU CD 465 Methods of Treatment
                                                   UMD CSD 5300 Lang Dis Chld, Adol
                                                   UMD CSD 8230 Neuro Lang Disord
Hearing, including the impact on
speech and language
● Prevention                                       NMU CD 351 Audiology
                                                   NMU CD 464 Methods of Diagnosis
                                                   NMU CD 351 Audiology
● Assessment                                       UMD CSD 5400 Rehab Procedures Hard
                                                   Hearing
                                                   NMU CD 465 Methods of Treatment
                                                   NMU CD 351 Audiology
● Intervention                                     UMD CSD 5400 Rehab Procedures Hard
                                                   Hearing
Swallowing
● Prevention                                       UMD CSD 5200 Dysphagia
● Assessment                                       UMD CSD 5200 Dysphagia
● Intervention                                     UMD CSD 5200 Dysphagia

Cognitive aspects of communication

● Prevention                                       NMU CD 356 Language Disorders




                                                                                      8                                                               Rev. 1/2010
                                                                                                   How Achieved?
                  A                   B                             C                                   D                                      E

                                  Knowledge/
                                   Skill Met?                                                                                 Other (e.g. labs, research) (Include
               Standards            (check )                Course # and Title            Practicum Experiences # and Title         description of activity)

                                                NMU CD 160 Anatomy of Sp & Hearing Mech
                                                NMU CD 356 Language Disorders
● Assessment                                    NMU CD 464 Methods of Diagnosis
                                                UMD CSD 5300 Lang Dis Chld, Adol
                                                UMD CSD 8230 Neuro Lang Disord
                                                NMU CD 356 Language Disorders
● Intervention                                  NMU CD 465 Methods of Treatment
                                                UMD CSD 5300 Lang Dis Chld, Adol
                                                UMD CSD 8230 Neuro Lang Disord
Social aspects of communication

● Prevention                                    NMU CD 356 Language Disorders
                                                UMD CSD 5300 Lang Dis Chld, Adol

                                                NMU CD 356 Language Disorders
● Assessment                                    NMU CD 464 Methods of Diagnosis
                                                UMD CSD 5300 Lang Dis Chld, Adol
                                                UMD CSD 8230 Neuro Lang Disord

                                                NMU CD 356 Language Disorders
● Intervention                                  NMU CD 465 Methods of Treatment
                                                UMD CSD 5300 Lang Dis Chld, Adol
                                                UMD CSD 8230 Neuro Lang Disord
Communication Modalities
● (Prevention not applicable)
                                                UMD CSD 5230 Assistive Tech
● Assessment                                    UMD CSD 5300 Lang Dis Chld, Adol
                                                UMD CSD 8230 Neuro Lang Disord

                                                NMU CD 356 Language Disorders
● Intervention                                  UMD CSD 5230 Assistive Tech
                                                UMD CSD 5300 Lang Dis Chld, Adol
                                                UMD CSD 8230 Neuro Lang Disord




                                                                                   9                                                               Rev. 1/2010
                                                                                           How Achieved?
                  A                           B                 C                               D                                      E

                                          Knowledge/
                                           Skill Met?                                                                 Other (e.g. labs, research) (Include
               Standards                    (check )    Course # and Title        Practicum Experiences # and Title         description of activity)
Standard IV-G: The applicant for
certification must complete a
program of study that includes
supervised clinical experiences
sufficient in breadth and depth to
achieve the following skills
outcomes (in addition to clinical
experiences, skills may be
demonstrated through successful
performance on academic course
work and examinations,
independent projects, or other
appropriate alternative methods):
1. Evaluation (must include all skill
outcomes listed in a-g below for
each of the 9 major areas)
a. Conduct screening and prevention
procedures (including prevention
activities)

b. Collect case history information
and integrate information from
clients/patients, family, caregivers,
teachers, relevant others, and other
professionals

c. Select and administer appropriate
evaluation procedures, such as
behavioral observations
nonstandardized and standardized
tests, and instrumental procedures
d. Adapt evaluation procedures to
meet client/patient needs

e. Interpret, integrate, and synthesize
all information to develop diagnoses
and make appropriate
recommendations for intervention




                                                                             10                                                            Rev. 1/2010
                                                                                                           How Achieved?
                   A                          B                              C                                  D                                      E

                                          Knowledge/
                                           Skill Met?                                                                                 Other (e.g. labs, research) (Include
              Standards                     (check )                 Course # and Title           Practicum Experiences # and Title         description of activity)
f. Complete administrative and
reporting functions necessary to
support evaluation
g. Refer clients/patients for
appropriate services
                                                        NMU CD 400 Phonological Disorders
                                                        NMU CD 210 Intro to Voice & Artic
                                                        NMU CD 464 Methods of Diagnosis          UMD CSD 8097 Internship CD
● Articulation                                          UMD CSD 8231 Neuro Sp Disor              UMD CSD 8197 Externship CD

                                                        NMU CD 464 Methods of Diagnosis
                                                        NMU CD 357 Fluency Disorders             UMD CSD 8097 Internship CD
● Fluency                                               UMD CSD 8205 Adv Fluency Disord          UMD CSD 8197 Externship CD
                                                        NMU CD 464 Methods of Diagnosis
● Voice and resonance, including                        UMD CSD 8200 Voice Disorders             UMD CSD 8097 Internship CD
respiration and phonation                               UMD CSD 8231 Neuro Sp Disor              UMD CSD 8197 Externship CD
● Receptive and expressive language
(phonology, morphology, syntax,                         NMU CD 356 Language Disorders
semantics, and pragmatics) in                           NMU CD 464 Methods of Diagnosis
speaking, listening, reading, writing,                  UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8097 Internship CD
and manual modalities                                   UMD CSD 8230 Neuro Lang Disord           UMD CSD 8197 Externship CD
                                                        NMU CD 464 Methods of Diagnosis
                                                        NMU CD 351 Audiology
● Hearing, including the impact on                      UMD CSD 5400 Rehab Procedures Hard       UMD CSD 8097 Internship CD
speech and language                                     Hearing                                  UMD CSD 8197 Externship CD
● Swallowing (oral, pharyngeal,
esophageal, and related functions,
including oral function for feeding;                    NMU CD 464 Methods of Diagnosis          UMD CSD 8097 Internship CD
orofacial myofunction)                                  UMD CSD 5200 Dysphagia                   UMD CSD 8197 Externship CD
● Cognitive aspects of communication                    NMU CD 356 Language Disorders
(attention, memory, sequencing,                         UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8097 Internship CD
problem-solving, executive functioning)                 UMD CSD 8230 Neuro Lang Disord           UMD CSD 8197 Externship CD
● Social aspects of communication
(including challenging behavior,                        NMU CD 356 Language Disorders
ineffective social skills, lack of                      UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8097 Internship CD
communication opportunities)                            UMD CSD 8230 Neuro Lang Disord           UMD CSD 8197 Externship CD




                                                                                            11                                                             Rev. 1/2010
                                                                                                          How Achieved?
                   A                          B                             C                                  D                                      E

                                          Knowledge/
                                           Skill Met?                                                                                Other (e.g. labs, research) (Include
              Standards                     (check )                Course # and Title           Practicum Experiences # and Title         description of activity)
● Communication modalities (including
oral, manual, augmentative, and                         NMU CD 356 Language Disorders
alternative communication techniques                    UMD CSD 5300 Lang Dis Chld, Adol        UMD CSD 8097 Internship CD
and assistive technologies)                             UMD CSD 8230 Neuro Lang Disord          UMD CSD 8197 Externship CD
2. Intervention (must include all skill
outcomes listed in a-g below for
each of the 9 major areas)

a. Develop setting-appropriate
intervention plans with measurable
and achievable goals that meet
clients'/patients' needs. Collaborate
with clients/patients and relevant
others in the planning process

b. Implement intervention plans
(involve clients/patients and relevant
others in the intervention process)
c. Select or develop and use
appropriate materials and
instrumentation for prevention and
intervention
d. Measure and evaluate
clients'/patients' performance and
progress
e. Modify intervention plans,
strategies, materials, or
instrumentation as appropriate to
meet the needs of clients/patients
f. Complete administrative and
reporting functions necessary to
support intervention

g. Identify and refer clients/patients
for services as appropriate




                                                                                           12                                                             Rev. 1/2010
                                                                                                           How Achieved?
                    A                         B                              C                                  D                                      E

                                          Knowledge/
                                           Skill Met?                                                                                 Other (e.g. labs, research) (Include
                 Standards                  (check )                Course # and Title            Practicum Experiences # and Title         description of activity)
                                                        NMU CD 400 Phonological Disorders
                                                        NMU CD 210 Intro to Voice & Artic
                                                        NMU CD 465 Methods of Treatment          UMD CSD 8097 Internship CD
● Articulation                                          UMD CSD 8231 Neuro Sp Disor              UMD CSD 8197 Externship CD
                                                        NMU CD 357 Fluency Disorders             UMD CSD 8097 Internship CD
● Fluency                                               UMD CSD 8205 Adv Fluency Disord          UMD CSD 8197 Externship CD
                                                        UMD CSD 8200 Voice Disorders             UMD CSD 8097 Internship CD
● Voice and resonance                                   UMD CSD 8231 Neuro Sp Disor              UMD CSD 8197 Externship CD

                                                        NMU CD 356 Language Disorders
                                                        NMU CD 465 Methods of Treatment
                                                        UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8097 Internship CD
● Receptive and expressive language                     UMD CSD 8230 Neuro Lang Disord           UMD CSD 8197 Externship CD
                                                        NMU CD 351 Audiology
● Hearing, including the impact on                      UMD CSD 5400 Rehab Procedures Hard       UMD CSD 8097 Internship CD
speech and language                                     Hearing                                  UMD CSD 8197 Externship CD
                                                                                                 UMD CSD 8097 Internship CD
● Swallowing                                            UMD CSD 5200 Dysphagia                   UMD CSD 8197 Externship CD
                                                        NMU CD 356 Language Disorders
                                                        UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8097 Internship CD
● Cognitive aspects of communication                    UMD CSD 8230 Neuro Lang Disord           UMD CSD 8197 Externship CD
                                                        NMU CD 356 Language Disorders
                                                        UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8097 Internship CD
● Social aspects of communication                       UMD CSD 8230 Neuro Lang Disord           UMD CSD 8197 Externship CD
                                                        NMU CD 356 Language Disorders            UMD CSD 8097 Internship CD
● Communication modalities                              UMD CSD 5300 Lang Dis Chld, Adol         UMD CSD 8197 Externship CD

3. Interaction and Personal Qualities
a. Communicate effectively,
recognizing the needs, values,
preferred mode of communication, and
cultural/linguistic background of the
client/patient, family, caregivers, and                 NMU CD 356 Language Disorders            UMD CSD 8097 Internship CD
relevant others.                                        UMD CSD 8235 Counseling Applic           UMD CSD 8197 Externship CD
b. Collaborate with other professionals                                                          UMD CSD 8097 Internship CD
in case management.                                     UMD CSD 8235 Counseling Applic           UMD CSD 8197 Externship CD




                                                                                            13                                                             Rev. 1/2010
                                                                                                        How Achieved?
                  A                          B                             C                                 D                                      E

                                         Knowledge/
                                          Skill Met?                                                                               Other (e.g. labs, research) (Include
                Standards                  (check )                Course # and Title          Practicum Experiences # and Title         description of activity)
c. Provide counseling regarding
communication and swallowing                           UMD CSD 8200 Voice Disorders
disorders to clients/patients, family,                 UMD CSD 8205 Adv Fluency Disord        UMD CSD 8097 Internship CD
caregivers, and relevant others.                       UMD CSD 8235 Counseling Applic         UMD CSD 8197 Externship CD
d. Adhere to the ASHA Code of Ethics                   NMU CD 464 Methods of Diagnosis        UMD CSD 8097 Internship CD
and behave professionally.                             UMD CSD 8210 Prof Issues               UMD CSD 8197 Externship CD




                                                                                         14                                                             Rev. 1/2010
                                              Knowledge and Skills Acquisition (KASA) Summary Form
                                                 For Certification in Speech-Language Pathology

                                                             Verification by Program Director
The applicant for certification:
  □ Yes      □ No      Has a master's or doctoral degree. A minimum of 75 semester credit hours were completed in a course of study addressing the
                       knowledge and skills pertinent to the field of speech-language pathology (Std. I)
 □ Yes       □ No      Initiated and completed all graduate course work and graduate clinical practicum in an institution whose program was accredited by
                       the CAA (Std. I)
  □ Yes       □ No     Has completed a program of study (a minimum of 75 semester credit hours overall, including at least 36 at the graduate level) that
                       includes academic course work sufficient in depth and breadth to achieve the specified knowledge outcomes (Std. III-A,B,C)
  □ Yes       □ No     Possesses knowledge of the principles and methods of prevention, assessment and intervention for people with communication and
                       swallowing disorders (Std. III-D)
  □ Yes       □ No     Has demonstrated knowledge of standards of ethical conduct (Std. III-E)
  □ Yes       □ No     Has knowledge of processes used in research and the integration of research principles into evidence-based clinical practice (Std. III-
                       F)
  □ Yes       □ No     Has demonstrated knowledge of contemporary professional issues (Std. III-G)
  □ Yes       □ No     Has demonstrated knowledge about certification, specialty recognition, licensure, and other relevant professional credentials (Std.III-
                       H)
  □ Yes       □ No     Has completed a curriculum of academic and clinical education that follows an appropriate sequence of learning sufficient to achieve
                       the skills outcomes in Standard IV-G (Std. IV-A)
  □ Yes       □ No     Possesses skill in oral and written and other forms of communication sufficient for entry into professional practice (Std. IV-B)
  □ Yes       □ No     Has completed a minimum of 400 clock hours of supervised clinical experience in the practice of speech-language pathology,
                       including 25 hours in clinical observation and 375 hours in direct client/patient contact (Std. IV-C)
  □ Yes       □ No     Has completed at least 325 clock hours while engaged in graduate study (Std. IV-D)
  □ Yes       □ No     Has been supervised by individuals holding a current ASHA Certificate of Clinical Competence in the appropriate area of practice.
                       The amount of supervision was appropriate to the student's level of knowledge, experience, and competence and the supervision
                       was sufficient to ensure the welfare of the client/patient populations (Std. IV-E)
  □ Yes       □ No     Has gained knowledge of and experience with individuals from culturally/linguistically diverse backgrounds and with client/patient
                       populations across the life span (Std. IV-F)
  □ Yes       □ No     The applicant has met the education program's requirements for demonstrating satisfactory performance through ongoing formative
                       assessment of knowledge and skills. (Std. V-A)

   The program director verifies that the student met each standard and has successfully met the education program's requirements for demonstrating
   satisfactory performance through ongoing assessment of knowledge and skills.

_____________________________________________________                            _____________________________________________________
Name                                                                             Program
_____________________________________________________
Title
_____________________________________________________                            ___________________________________
Signature                                                                        Date

                                                                               11
                                                                          January, 2003