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 | Hearing Clinic at SUNY Geneseo
 | Clinical Evaluation Form for CDSc 581: Clinical Practicum in Audiology
 | Student's Name:
 | Supervisor's Name:
 | Mid-Semester Rating: |  |  |  |  | Date: |  | Final Rating: |  | Date:
 | (Mid-Semester: S=Satisfactory, U=Unsatisfactory)
 | I. | Preparation for Clinical Sessions |  |  |  |  |  |  |  | Proficient | Sufficient | Developing | Insufficient | Not Applicable |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | client | GRADE
 |  | A. | Ability to set up audiometric equipment prior to each clinical session. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Adult | S
 |  | B. | Ability to conduct a basic listening check of the audiometer. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Child | U
 |  | C. | Ability to review, understand and integrate information available from previous evaluations (e.g., audiological, medical, speech-language, educational etc), including background information and test results.
 |  | D. | Ability to modify the test environment relative to factors associated with access, safety, distractibility, etc.
 | II. | Counseling |  |  |  |  |  |  |  | Proficient | Sufficient | Developing | Insufficient | Not Applicable |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Grades
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | A
 |  | A | Ability to assist in conducting a case history interview. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | A-
 |  | B | Ability to explain test results and provide information. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]
 |  | C | Ability to listen and demonstrate empathy toward client and family. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | B
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | B-
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | C+
 | III. | Administration of Audiologic Tests/Procedures |  |  |  |  |  |  |  | Proficient | Sufficient | Developing | Insufficient | Not Applicable |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | C
 |  | A. | Ability to give clear, concise directions, and to reinstruct and/or modify directions as needed. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | C-
 |  | B. | Ability to conduct an otoscopic examination. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | D
 |  | C. | Ability to conduct acoustic immittance testing. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | E
 |  | D. | Ability to conduct pure tone hearing screenings.
 |  | E. | Ability to conduct pure tone air conduction threshold testing.
 |  | F. | Ability to record pure tone air conduction threshold results onto an audiogram.
 |  | G. | Ability to modify assessment protocol as needed.
 | IV. | Guided Interpretation of Audiologic Tests/Procedures |  |  |  |  |  |  |  | Proficient | Sufficient | Developing | Insufficient | Not Applicable
 |  | A. | Ability to accurately interpret otoscopic findings.
 |  | B. | Ability to accurately interpret acoustic immittance results.
 |  | C. | Ability to accurately interpret pure tone hearing screening results.
 |  | D. | Ability to accurately interpret pure tone air conduction threshold results.
 | V. | Behavioral Management |  |  |  |  |  |  |  | Proficient | Sufficient | Developing | Insufficient | Not Applicable
 |  | A. | Ability to set and enforce limits/expectations in response to the level of client motivation or resistance.
 |  | B. | Ability to use effective reinforcement.
 | VI. | Personal and Professional |  |  |  |  |  |  |  | Proficient | Sufficient | Developing | Insufficient | Not Applicable
 |  | A. | Ability to build rapport with client and family.
 |  | B. | Ability to provide a good visual/auditory model when interacting with clients (e.g., use of Clear Speech, communication strategies).
 |  | C. | Ability to communicate commensurate with client's skills.
 |  | D. | Ability to respond to supervisory recommendations and evaluations in an open, non-defensive manner.
 |  | E. | Ability to reflect on their recent clinical performance and accurately self-evaluate.
 |  | F. | Ability to implement supervisor's recommendations in future sessions.
 |  | G. | Ability to demonstrate independence and self-confidence in select clinical skills.
 |  | H. | Ability to effectively communicate audiologic results to supervisor.
 |  | I. | Ability to adhere to the ASHA Code of Ethics.
 |  | J. | Ability to maintain client confidentiality.
 |  | K. | Ability to present oneself in a professional manner (e.g., attitude, conduct, dress, prompt notification of supervisor when unable to attend a session).
 |  | L. | Ability to maintain an accurate log of clinical practicum hours.
 | COMMENTS:
 | We have discussed the information contained within this document on |  |  |  |  |  |  |  |  |  | .
 | ______________________________________________                   ____________________________________________
 | Student Signature |  |  |  |  |  |  | Clinical Supervisor Signature
 |  |  |  |  |  |  |  |  |  |  |  | Rev. 07/09 | 2011-03-01 00:00:00