End of Semester General Clinic Checksheet

END OF SEMESTER GENERAL CLINIC CHECKSHEET

The student(s) is to complete this form prior to meeting with the CI. The CI completes his/her portion of this form during the student’s final meeting. Only one form needs to be completed per client. Paired students are to complete the form together; one student takes this form and client chart to his/her meeting. CI will turn into Kim West upon completion.

CLIENT’S NAME ______CLINICIAN(S)______CI______

SC= Student Clinician CI=Clinical Instructor Place check when each item is completed. SC CI CLIENT FILE End of Semester Client File Contents and Semester Audit Form: Completed and filed. File: Client files are neat and tidy. SC CI CLOCK HOURS CALIPSO: During the semester, student entered all clockhours and CI approved. CALIPSO: Student printed a copy for his/her records 1) Clockhours List (lists each time hours were entered and approved), and 2) Clockhours Experience (lists cumulative hours; combines all semesters) SC CI Evaluations CALIPSO: CI completed the Mid and Final Student Evaluations. CALIPSO: Student completed the Mid and Final Self-Evaluations. CALIPSO: Student completed the Supervisor Evaluation. SC Housekeeping Materials room: Returned tests, materials and equipment. Personal items: Removed items from student workroom, clinic treatment rooms and mailbox. Treatment room: Cleaned tables, mirror (both sides), white board, sink. Stocked room. Reported any problems.

Is client returning next semester? ______Circle one: SUMMER FALL SPRING DISCHARGED

SERVICES TERMINATED – REASON: ______

Primary Diagnosis: ______Secondary Diagnosis: ______

Intervention targeted the following areas:

 Articulation ______

 Receptive Language ______

 Expressive Language ______

 Fluency ______

 Voice and Resonance ______

 Hearing ______

 Swallowing and Feeding ______

 Cognitive Aspects ______

 Social Aspects ______ Communication Modalities ______

Is a diagnostic recommended for the beginning of next semester? ______If so, which one(s)? ______

Student Signature ______Clinical Instructor’s Signature ______