UWW - ASHA HOUR FORM

Instructions for filling out the Workbook

1. Enter your contact hours for each client in the worksheets labled C (1) through C (10).
Hours must be in decimal notation. If you are not sure on how to convert minutes
to a decimal notation use the "min-decimal converter" worksheet.
2. Hour sheets must not be saved on lab computers.
3. Make sure that you backup your work. You will be updating the workbook each semester.
4. After updating the worksheets, print off a copy of the summary and all worksheets
that require a supervisor's signature.
If the sheet takes up more than one printed page go to the Page Setup Menu
and change the scaling to "Fit to: 1 page tall and 1 page wide"
5. Be sure to turn in signed copies of your hours worksheets and summary
to the clinic supervisor.
6. You may change to name of the worksheets by double clicking on the tab at the
bottom of the sheet and typing in a new name.
For example, you can change C (1) to read Spring 04 - <supervisor's name>
Use this Worksheet to convert minutes to a decimal notation.
decimal decimal
minutes equivalent minutes equivalent
60 1.00 30 0.50
59 0.98 29 0.48
58 0.97 28 0.47
57 0.95 27 0.45
56 0.93 26 0.43
55 0.92 25 0.42
54 0.90 24 0.40
53 0.88 23 0.38
52 0.87 22 0.37
51 0.85 21 0.35
50 0.83 20 0.33
49 0.82 19 0.32
48 0.80 18 0.30
47 0.78 17 0.28
46 0.77 16 0.27
45 0.75 15 0.25
44 0.73 14 0.23
43 0.72 13 0.22
42 0.70 12 0.20
41 0.68 11 0.18
40 0.67 10 0.17
39 0.65 9 0.15
38 0.63 8 0.13
37 0.62 7 0.12
36 0.60 6 0.10
35 0.58 5 0.08
34 0.57 4 0.07
33 0.55 3 0.05
32 0.53 2 0.03
31 0.52 1 0.02
ASHA HOUR FORM - SUMMARY - UW WHITEWATER
STUDENT NAME: Allison Zimmerman
SEMESTER/YEAR: Fall/2013
On-Campus Off-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0 2.163 1 0 0 0 2.333 0.83 3.163
intervention 4.5 12 10.583 0 0 4.5 5.583 21.5 27.083
Fluency evaluation 0 0 0 0 0 0 0 0 0
intervention 0 0 0 0 0 0 0 0 0
Voice and evaluation 0 0 0 0 0 0 0 0 0
Resonance intervention 0 0 0 0 0 0 0 0 0
Receptive and Speaking/Listening
Expressive evaluation 0 1.5 0 0 0 0 1.5 0 1.5
Language intervention 0 2.5 0 0 0 0 0 2.5 2.5
Writing/Reading
evaluation 0 0.166 0 0 0 0 0.166 0 0.166
intervention 0 0 2.75 0 0 0 0 2.75 2.75
Manual
evaluation 0 0 0 0 0 0 0 0 0
intervention 0 0 0 0 0 0 0 0 0
Hearing evaluation 0 5.67 0 0 0 0 2 3.67 5.67
intervention 0 0 0 0 0 0 0 0 0
Swallowing evaluation 0 0 0 0 0 0 0 0 0
intervention 0 0 0 0 0 0 0 0 0
Cognitive Aspects evaluation 0 0 0 0 0 0 0 0 0
of Communication intervention 0 2.67 0 0 0 0 0 2.67 2.67
Social Aspects evaluation 0 0 0 0 0 0 0 0 0
of Communication intervention 0 0 0 0 0 0 0 0 0
AAC Assistive evaluation 0 0 0 0 0 0 0 0 0
Technology intervention 0 0 0 0 0 0 0 0 0
Summary of Hours by Age & CLD 4.5 26.669 14.333 0 0 4.5 11.582 33.92
Total Number of Hours 45.502
Student Signature __________________________________________________ Date:
Clinic Coordinator __________________________________________________ Date:
Signature
ASHA Acount Number ______________________
(revised 5/15/2013/sb)
ASHA HOUR FORM - UW WHITEWATER
Student Name: Allison Zimmerman
Practicum Setting: Williams Bay Elementary
Semester/Year/
Supervisor Fall/2013/Dana Syring
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0.83 0.83 0.83
intervention 3 10.33 3 2.5 16.33 16.33
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 3.67 3.67 3.67
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 2.67 2.67 2.67
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 3 17.5 3 0 0 2.5 0 23.5
Total Number of Hours 23.5
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name: Allison Zimmerman
Practicum Setting: Washington Elementary School
Semester/Year/
Supervisor Fall/2013/Melanie Lindstrum
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 1.5 1.67 2 2 5.17 5.17
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 2.5 2.5 2.5
Writing/Reading
evaluation 0
intervention 2.75 2.75 2.75
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 1.5 4.17 4.75 0 0 2 0 10.42
Total Number of Hours 10.42
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name: Allison Zimmerman
Practicum Setting: UWW-CCD
Semester/Year/
Supervisor Fall/2013/Beth Miller Swanson
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 1.333 1 2.333 2.333
intervention 5.583 5.583 5.583
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 1.5 1.5 1.5
Language intervention 0
Writing/Reading
evaluation 0.166 0.166 0.166
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 2 2 2
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 4.999 6.583 0 0 0 11.582 0
Total Number of Hours 11.582
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________
ASHA HOUR FORM - UW WHITEWATER
Student Name:
Practicum Setting:
Semester/Year/
Supervisor
On-CampusOff-Campus Total Hours
Birth to 3 >3 to 6 >6 to 12 >12 to 18 Adult CLD* Hours Hours by Category
*Hours noted in the Culturally/Linguistically Diverse (CLD) category
are not included in the total number of hours
Articulation evaluation 0
intervention 0
Fluency evaluation 0
intervention 0
Voice and evaluation 0
Resonance intervention 0
Receptive and Speaking/Listening
Expressive evaluation 0
Language intervention 0
Writing/Reading
evaluation 0
intervention 0
Manual
evaluation 0
intervention 0
Hearing evaluation 0
intervention 0
Swallowing evaluation 0
intervention 0
Cognitive Aspects evaluation 0
of Communication intervention 0
Social Aspects evaluation 0
of Communication intervention 0
AAC Assistive evaluation 0
Technology intervention 0
Summary of Hours by Age & CLD 0 0 0 0 0 0 0 0
Total Number of Hours 0
Student Signature __________________________________________________ Date: ______________
Supervisor Signature __________________________________________________ Date: ______________
ASHA Certification: SLP A ASHA Account Number: _______________