<p> University of South Florida Audiology Evaluation Form - Year Four</p><p>NAME ______Site______</p><p>Supervisor ______Term ______</p><p>AREA MIDTERM GRADE FINAL GRADE</p><p>Letter Numeric Letter Numeric Interpersonal Communication</p><p>Planning</p><p>Assessment Skills-Adult </p><p>Assessment Skills-Pediatric</p><p>Assessment Skills-Specialty</p><p>Amplification Counseling, Recommendations and Referrals</p><p>Written Documentation</p><p>Auditory/Vestibular Rehabilitation Professionalism/ Clinical Problem Solving</p><p>SUBTOTAL</p><p>OVERALL AVERAGE GRADE</p><p>SCALE: A+ = 8.0-7.8 B+ = 5.9-5.0 C = 2.9-2.0 A = 7.7-7.0 B = 4.9-4.0 D/F = 1.9 and below A- = 6.9-6.0 B- = 3.9-3.0</p><p>RATING SCALE with SUPERVISION CONTINUUM Outstanding Excellent Excellent Above Average Average Below Average Unsatisfactory Absent A+ = 8 A = 7 A- = 6 B+ = 5 B = 4 B- = 3 C = 2 D/F = 1 Competency Competency Competency/ Competency / Competency/skill Competency/ Competency/ Competency/skill /skill well- /skill developed skill developed skill present but demonstrated but skill emerging but skill demonstrated not evident. developed and but needs but needs needs further inconsistent. inconsistent. only with Requires constant consistent. refinement. refinement and development. Requires Requires supervisor model . monitoring and Requires Requires consistency. Requires frequent frequent Requires modeling. guidance and infrequent Requires some frequent monitoring and monitoring and constant consultation monitoring. monitoring. monitoring. occasional frequent monitoring and only. modeling. modeling. frequent modeling.</p><p>1 Instructions:  Circle the appropriate rating on the 8 point scale for each competency area.  A rating of “B” or better must be achieved in each competency area to demonstrate adequate performance.  The average of the ratings for the 10 competency areas is used to determine the overall clinical rating.  Indicate NA (not applicable) for areas that are unable to be assessed due to limited opportunities or exposure.</p><p>Below Av Above Unsatisfactor Outstanding Excellent Excellent Average er Absent Interpersonal Communication Average y ag e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final</p><p>Effectively communicates and collaborates with patients, families, caregivers and other professionals. 8 7 6 5 4 3 2 1</p><p>Below Av Above Unsatisfactor Outstanding Excellent Excellent Average er Absent Average y Planning ag e A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final Conducts appropriate pre-assessment planning. 8 7 6 5 4 3 2 1</p><p>Below Above Ave Outstanding Excellent Excellent Average Unsatisfactory Absent Assessment Skills- Adult Average rag e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final</p><p>Obtains a complete case history. 8 7 6 5 4 3 2 1</p><p>Effectively conducts an adult hearing evaluation (air, bone & speech) with and without masking. 8 7 6 5 4 3 2 1</p><p>Effectively conducts immittance measures. 8 7 6 5 4 3 2 1</p><p>Effectively conducts otoacoustic emissions testing. 8 7 6 5 4 3 2 1</p><p>Recognizes the need for cerumen removal. 8 7 6 5 4 3 2 1</p><p>2 Average – Assessment Skills/Adult</p><p>Below Above Ave Outstanding Excellent Excellent Average Unsatisfactory Absent Assessment Skills- Pediatric Average rag e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final</p><p>Obtains a complete case history. 8 7 6 5 4 3 2 1 Effectively conducts a developmentally appropriate pediatric hearing evaluation with and without masking. 8 7 6 5 4 3 2 1</p><p>Effectively conducts immittance measures. 8 7 6 5 4 3 2 1</p><p>Effectively conducts otoacoustic emissions testing. 8 7 6 5 4 3 2 1</p><p>Recognizes the need for cerumen removal. 8 7 6 5 4 3 2 1</p><p>Average – Assessment Skills/Pediatric</p><p>Below A Above ve Assessment Skills- Specialty Outstanding Excellent Excellent Average Unsatisfactory Absent Average ra g e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final Effectively conducts advanced assessment measures: a. ABR/EcochG 8 7 6 5 4 3 2 1 b. ENG/VNG 8 7 6 5 4 3 2 1 c. Balance evaluation 8 7 6 5 4 3 2 1 d. Evoked potentials ((MLR, LLR) 8 7 6 5 4 3 2 1 e. Auditory processing evaluation 8 7 6 5 4 3 2 1</p><p>Average – Assessment Skills/Specialty 3 Below A Above ve Amplification Outstanding Excellent Excellent Average Unsatisfactory Absent Average ra g e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final Appropriately recommends, selects, fits, maintains and troubleshoots: a. Hearing aid(s) 8 7 6 5 4 3 2 1</p><p> b. Assistive listening device 8 7 6 5 4 3 2 1</p><p> c. Cochlear implant 8 7 6 5 4 3 2 1</p><p>Average – Amplification</p><p>Below A Above ve Counseling, Recommendations and Referrals Outstanding Excellent Excellent Average Unsatisfactory Absent Average ra g e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final</p><p>Provides appropriate counseling, follow-up recommendations and referrals. 8 7 6 5 4 3 2 1</p><p>Below A Above Outstanding Excellent Excellent Average ve Unsatisfactory Absent Average Written Documentation ra ge</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final Provides accurate and concise documentation (reports, chart notes, etc.). 8 7 6 5 4 3 2 1</p><p>Outstanding Excellent Excellent Above Average Below Unsatisfactory Absent Average A Auditory/Vestibular Rehabilitation ve ra ge</p><p>4 A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final Implements, conducts and assesses appropriate rehabilitation measures: a. Aural rehabilitation 8 7 6 5 4 3 2 1 b. Vestibular rehabilitation 8 7 6 5 4 3 2 1</p><p>Average – Auditory/Vestibular Rehabilitation</p><p>Below A Above ve PROFESSIONALISM/ Outstanding Excellent Excellent Average Unsatisfactory Absent CLINICAL PROBLEM SOLVING Average ra g e</p><p>A+=8 A=7 A- =6 B+= 5 B=4 B- =3 C= 2 D/F=1 Midterm Final</p><p>Demonstrates professionalism. 8 7 6 5 4 3 2 1 Demonstrates appropriate clinical problem solving abilities. 8 7 6 5 4 3 2 1</p><p>Average – Professionalism/Clinical Problem Solving</p><p>AREAS OF STRENGTH</p><p>Midterm:</p><p>Final:</p><p>AREAS FOR FURTHER DEVELOPMENT</p><p>Midterm:</p><p>Final:</p><p>5 MIDTERM EVALUATION FINAL EVALUATION</p><p>______Graduate Clinician Graduate Clinician</p><p>______Site Preceptor Site Preceptor</p><p>6 7</p>